DSAEK Descemetorhexis in Two Patients with Anterior Segment Fibrosis after Multiple Intraocular Surgeries

Abstract

 

Purpose

 

To report clinical and histopathologic findings of the posterior cornea in two patients with a history of multiple intraocular procedures and to describe a surgical approach for descemetorhexis in these cases.

 

Methods

 

Interventional case series.

 

Results

 

Two patients developed unilateral bullous keratopathy following pars plana vitrectomies, cataract surgeries, and glaucoma filtering surgeries with multiple anterior chamber drainage devices. Both underwent Descemet’s stripping automated endothelial keratoplasty that was complicated by difficult descemetorhexis due to fibrotic posterior corneal tissue seen intraoperatively that was consistent with stromal downgrowth on histopathologic analysis. In these cases, descemetorhexis necessitated unconventional instruments including a reverse cystotome and intraocular scissors. Both patients developed detachments of the endothelial grafts and subsequent re-bubbling procedures.

 

Conclusions

 

Patients with bullous keratopathy secondary to multiple surgeries and anterior segment surgical implants may pose intraoperative challenges due to thickened and scarred posterior corneal tissue. It is imperative for surgeons performing endothelial keratoplasty on such patients to consider unique approaches to descemetorhexis as described herein or alternative techniques such as endothelial keratoplasty without Descemet stripping, penetrating keratoplasty, and deep lamellar endothelial keratoplasty.

 

 

Figure 1. A. Thickened and fibrotic Descemet’s membrane (black arrow) and clear Descemet’s membrane (white arrow) in the same tissue plane during descemetorhexis. B. Removal of Descemet’s membrane with intraocular scissors. The superonasal glaucoma drainage device is not visualized.

 

 

Figure 2. A, B. Case 1 - Descemet’s membrane is of normal thickness, with a tightly attached region of dense stromal downgrowth containing scattered pigment granules (arrows) within the spindled cells (original magnification 200X). C. Case 2 - A thick retrocorneal membrane is present, with normal appearing Descemet’s membrane and complete endothelial loss (original magnification 200X). D, E. Case 2 - Rare pigment granules are entrapped within the stromal downgrowth (Arrow, original magnification 400X).

 

Keywords: 481 cornea: endothelium