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Kelly M. Bui, Elmer Y. Tu; A Rigid Band of Retained Descemet's Membrane as a Mechanical Cause of Graft Non-attachment in Repeat DSAEK. Invest. Ophthalmol. Vis. Sci. 2011;52(14):759.
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Descemet’s stripping automated endothelial keratoplasty (DSAEK) has become the preferred method of corneal transplantation for endothelial disease with improved safety, reduced astigmatism, and faster visual recovery. However, graft non-adherence remains a common complication of primary DSAEK in the early post-operative period, which is usually responsive to additional air bubbling and/or graft repositioning. Persistent non-attachment is unusual and has been attributed to donor-graft interface abnormalities or traumatic endothelial cell loss. We describe a unique mechanism preventing attachment in cases of repeat DSAEK, which required surgical modification of the host cornea.
Retrospective chart review of repeat DSAEK cases complicated by early graft dislocation.
Two patients were identified who experienced early DSAEK graft dislocation which did not resolve with traditional techniques. Patient 1, previously diagnosed with Fuchs endothelial dystrophy, experienced corneal decompensation after an uncomplicated CE/PCIOL. Initial DSAEK was successful at achieving BCVA of 20/40, but failed secondary to peripheral graft dehiscence after 8 months. Patient 2 developed PBK in his remaining eye 30 years after ICCE and closed loop ACIOL placement. Initial DSAEK yielded BCVA of 20/50 but the cornea thickened with a corresponding decrease in vision after 2 years. Repeat DSAEK grafts in both patients were non-adherent and failed simple air augmentation. Pathology of the explanted button from patient 1 demonstrated exuberant growth of Descemet’s membrane around the edge of the lenticule and clinical exam revealed a band of residual Descemet’s membrane lifting an edge of the transplant. Stripping of the band resulted in successful attachment in both patients. Stripping was combined with lenticule replacement in patient 2 because of >6 weeks of non-attachment.
Early graft dislocation in repeat DSAEK may be due to direct mechanical obstruction from rigid, retained Descemet’s membrane formed around the edge of previous DSAEK lenticule. Early identification and complete removal may prevent prolonged dislocation and need for repeat DSAEK.
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