Corneal clearance and central endothelial cell repopulation despite graft detachment after Descemet membrane endothelial keratoplasty

A Case of Transparent Cornea Maintained after Removal of Dislocated Graft from Descemet's Stripping Automated Endothelial Keratoplasty

Introduction

Corneal graft detachment is a major postoperative complication of Descemet's stripping automated endothelial keratoplasty (DSAEK). When a corneal graft becomes detached, corneal endothelial function generally fails, and repeat corneal transplantation is required. Herein, we report a rare case in which a transparent cornea was maintained after the removal of a dislocated DSAEK graft.

Case Presentation

A 79-year-old woman with a residual lens cortex who had undergone cataract surgery was referred to our hospital. The cortex was removed, and bullous keratopathy progressed. Six months after the initial surgery, DSAEK was performed under topical anesthesia without any complications. Although the corneal graft had attached fairly well, it detached from the host cornea 3 weeks later. Two months after DSAEK, an air tamponade was used to treat the anterior chamber with single interrupted suturing; however, the graft detached again, except for the suture site. Because the detached cornea became cloudy in the anterior chamber, it was surgically removed 8 months after DSAEK. Accordingly, the host cornea transparency improved to a best-corrected visual acuity of 0.8 with a rigid gas permeable lens and a central corneal thickness of 580 μm. The corneal endothelial cell density was 995 cells/mm2.

Conclusion

Removal of the corneal graft from the dislocated cloudy graft improved the visual acuity of this patient after DSAEK. The condition of the cornea should be carefully monitored after corneal endothelial transplantation, even after the graft has been dislocated.

Visual Recovery and Endothelial Repopulation after DMEK Graft Removal and Vitrectomy for Late Endophthalmitis: A Case Report

Introduction

The aim of the study was to report a unique case with excellent clinical outcomes after late endophthalmitis following Descemet's membrane endothelial keratoplasty (DMEK) surgery requiring donor graft removal without replacement.

Case Presentation

A 67-year-old female with a prior ocular history of bilateral cataract surgery, Fuchs endothelial dystrophy, and pseudophakic DMEK in the left eye presented with endophthalmitis 2 months after keratoplasty. DMEK graft removal without replacement with an intracameral washout, pars plana vitrectomy, intracameral, and intravitreal antibiotics resulted in an excellent visual outcome (20/25).

Conclusion

This is a unique case of late endophthalmitis following DMEK surgery requiring graft removal and pars plana vitrectomy with excellent visual recovery without donor replacement.

Re-Endothelialization of Bare Stroma after Descemet's Detachment due to Macroperforation during Deep Anterior Lamellar Keratoplasty

Purpose

To report a case with spontaneous re-endothelialization of bare stroma after subtotal detachment of Descemet's membrane (DM) due to macroperforation during deep anterior lamellar keratoplasty (DALK).

Methods

Case report.

Results

A 64-year-old patient underwent DALK for deep stromal scarring secondary to herpetic keratitis. During manual dissection, DM macroperforation occurred, and this was successfully managed intraoperatively and postoperatively. The DM with host posterior stroma remained attached for 10 months when it detached from the bare donor stroma. The cornea remained clear, with uncorrected distance visual acuity (UCVA) of 0.17 logMAR. After graft suture removal 30 months later, he was noted to have regular astigmatism and cataract for which he underwent phacoemulsification with toric intraocular lens implantation. Twenty-four months following his cataract surgery and 58 months following his DALK, his UCVA remains 0.17 logMAR and the cornea remains clear with no evidence of edema. His average specular count at 58 months was 1296 cell/mm² .

Conclusion

This case shows a very good visual outcome with clear cornea at 58 months despite of large DM detachment which happened 10 months following manual DALK with intraoperative macroperforation.

Regenerative medicine in Fuchs' endothelial corneal dystrophy

The management of Fuchs' endothelial corneal dystrophy (FECD) has evolved rapidly since the introduction of endothelial keratoplasty (EK). In recent years, advances in our understanding of endothelial cell biology, in particular with respect to the regenerative capacity of endothelial cells, have opened the door to novel therapeutic options that stray from the traditional paradigm of allograft transplantation. We review the development of descemetorhexis without EK (DWEK) as a primary treatment for FECD and discuss the lessons learned to date about the mechanism of wound healing, surgical technique, patient selection, and refractive outcomes. Multiple randomized clinical trials are currently underway to evaluate the potential for pharmacological supplementation with rho-associated kinase inhibitors to increase the success rate of corneal clearance following DWEK. Biologic supplementation with intracameral endothelial cell injection and acellular Descemet's membrane transplantation are other avenues of adjuvant therapy. DWEK is a promising surgical option for management of a subset of FECD patients.