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Chi-Ying Chou, Sonul Gajree, Kanna Ramaesh, Deepa R Sivadasan Anijeet; Spontaneous double anterior chamber following DALK. Invest. Ophthalmol. Vis. Sci. 2017;58(8):5684.
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© ARVO (1962-2015); The Authors (2016-present)
Descemet’s membrane detachment (DMD) and formation of double anterior chamber (DAC) is an uncommon complication of deep anterior lamellar keratoplasty (DALK). Previously reported incidence range from 4% in keratoconus patients to 13.8% in therapeutic DALK for fungal keratitis. We wish to illustrate 2 cases of spontaneous DAC in elderly patients immediately following DALK without apparent intraoperative perforations.
Retrospective case report of 2 patients with DAC following uncomplicated DALK. The clinical indication of graft, course of treatment and possible causes are discussed.
Both patients are elderly females (74 and 81 years old respectively) with elective lamellar grafts. Surgeries were uncomplicated and grafts secured with 16 interrupted sutures without apparent perforation. Patient one is a healed acanthomoeba keratitis with resultant corneal scaring. Manual dissection was adopted, baring corneal stroma to pre-Descemet’s layer. Donor button with intact endothelium secured. DAC was noted a week later. Despite repeated air injections, the interface fluid could not be reduced. Graft remained clear, thus recipient corneal bed was removed. Patient two had longstanding bilateral corneal scarring of unknown cause. Uncomplicated Anwar’s Big Bubble technique was achieved and donor button without endothelium was secured. Complete DMD was noted on day 1. Air bubble injection postoperatively achieved DMD reattachment.
The most common cause of DMD after DALK is intraoperative perforation of the recipient Descemet's membrane. The etiology of spontaneous DMD however, is not fully understood. DM tear was not apparent intra or post-operatively in either of our cases, although microperforations are difficult to detect. Spontaneous consecutive bilateral DMD following cataract surgery has been reported before. It is suggested that some patients have anatomical predisposition for DMD due to weak stromal fibrillary attachments. Whether age related, reduced endothelial function had any role in DMD, though speculative, is worth pursuing by means of larger studies. These and other unknown factors may have led to spontaneous DMD in our patients.
This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.
Fig 1a, b. DAC following manual DALK demonstrated by slitlamp and AS-OCT (Visante®). 1c, d. Post removal of residual recipient bed with clear visual axis.
Fig 2a, b. Slitlamp and AS-OCT (Visante ®) images showing detached host DM. c. One week after air injection showing DM reattachment.
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