Role of Anterior Segment OCT for Descemet Membrane Stripping During Descemet Membrane Endothelial Keratoplasty in Eyes With Congenital Hereditary Endothelial Dystrophy

A 65-year-old patient with history of keratoconus, mild cataract and penetrating keratoplasty over 30 years ago developed corneal oedema subsequent of graft failure with best corrected visual acuity (BCVA) of counting fingers. He underwent a successful cataract surgery combined with a 7.25 mm Descemet’s Membrane Endothelial Keratoplasty (DMEK) with Sodium Hexafluoride (SF6) gas. His cornea remained oedematous inferiorly at 4 weeks, despite two subsequent re-bubbling due to persistent DMEK detachment inferiorly. This was managed by three radial full thickness 10-0 nylon sutures placed in the inferior cornea along with intracameral injection of air. Following this, his anterior segment ocular coherence tomography (OCT) confirmed complete attachment of the graft, and the sutures were removed 4 weeks later. Unaided visual acuity was 20/63 and BCVA was 20/32 after 8 months. DMEK suturing can be helpful in persistent DMEK detachments, which is refractory to repeated re-bubbling due to uneven posterior surface of previous PK.

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Descemet Membrane Endothelial Keratoplasty in Congenital Hereditary Endothelial Dystrophy

Cornea ◽

10.1097/ico.0000000000002701 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Vikas Mittal ◽

Nancy Sehdev ◽

Ruchi Mittal

Keyword(s):

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Descemet Membrane ◽

Congenital Hereditary Endothelial Dystrophy

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Epithelial downgrowth after Descemet membrane endothelial keratoplasty

European Journal of Ophthalmology ◽

10.1177/1120672120912413 ◽

2020 ◽

pp. 112067212091241

Author(s):

Viet Nhat Hung Le ◽

Florian Wabnig ◽

Bjoern Bachmann ◽

Claus Cursiefen

Keyword(s):

Anterior Segment ◽

Corneal Edema ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Visual Axis ◽

Corneal Incision ◽

Descemet Membrane ◽

Clear Corneal Incision ◽

Close Observation ◽

Histopathologic Evaluation

Purpose: To describe a patient with epithelial downgrowth after Descemet membrane endothelial keratoplasty. Methods: Case report. Results: A 73-year-old woman underwent triple Descemet stripping automated endothelial keratoplasty for cataract and corneal edema secondary to Fuchs endothelial dystrophy in the left eye elsewhere. Three years later, Descemet membrane endothelial keratoplasty was performed at our department due to graft failure. One month after the operation, her vision improved to 20/32 and maintained stable. At the 14-month visit, her visual acuity decreased, and a routine examination revealed epithelial downgrowth at the posterior surface of the cornea and partly beneath the graft, accompanied by presumed graft rejection. Therefore, repeat Descemet membrane endothelial keratoplasty with epithelial scraping and intracameral injection of 5-fluorouracil was indicated. She recovered 20/25 vision by 1 month after the surgery. However, small sheet-like epithelial downgrowth recurred 1 month later. The epithelial downgrowth was limited to the peripheral margin of the Descemet membrane endothelial keratoplasty graft and did not affect the visual axis. Epithelial downgrowth showed “islands” with connection between epithelial downgrowth and clear corneal incision on anterior segment optical coherence tomography images. Histopathologic evaluation of the removed Descemet membrane endothelial keratoplasty graft confirmed conjunctival epithelium as the source. Under close observation at the current 4-year follow-up, the epithelial downgrowth remained stable and localized and her vision increased to 20/20. Conclusion: Epithelial downgrowth can occur after Descemet membrane endothelial keratoplasty. The limited progression of epithelial downgrowth in this patient suggests that this condition after Descemet membrane endothelial keratoplasty even in the recurrence stage may cause less damage than expected and may only need to be observed closely if no progression occurs.

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Descemet Membrane Endothelial Keratoplasty in Toxic Anterior Segment Syndrome

Cornea ◽

10.1097/ico.0000000000002524 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Kara Necip ◽

Refik Oltulu ◽

Dogan Levent ◽

Gundogan Ali Osman

Keyword(s):

Anterior Segment ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Descemet Membrane ◽

Toxic Anterior Segment Syndrome

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Anterior segment reconstruction with artificial iris and Descemet membrane endothelial keratoplasty: a staged surgical approach

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2020-317906 ◽

2021 ◽

pp. bjophthalmol-2020-317906

Author(s):

Marcus Ang ◽

Donald Tan

Keyword(s):

Surgical Approach ◽

Central Corneal Thickness ◽

Intraoperative Complications ◽

Corneal Thickness ◽

Anterior Segment ◽

Endothelial Keratoplasty ◽

Descemet Membrane Endothelial Keratoplasty ◽

Descemet Membrane ◽

Artificial Iris ◽

Corneal Decompensation

PurposeTo describe a surgical approach that involves anterior segment reconstruction with CustomFlex Artificial Iris (CAI; HumanOptics, Erlangen, Germany) followed by Descemet membrane endothelial keratoplasty (DMEK) in complex eyes with corneal decompensation.MethodsRestrospective case series of eyes that underwent anterior segment restoration involving (1) synechiolysis of peripheral anterior synechiae and excision of iris remnants, (2) securing a well-fixated posterior chamber intraocular lens and (3) suture-fixated or capsular bag placement of CAI. All eyes then underwent DMEK using a pull-through technique with the DMEK EndoGlide (Network Medical Products, Ripon, UK). Main outcomes were successful anterior segment restoration and corneal clarity with central corneal thickness (CCT).ResultsFive eyes of five patients (median age 61 years, range 27–69 years; 60% female) underwent anterior segment reconstruction with CAI implantation (4 suture-fixated), followed by successful DMEK surgery (median 2 months later, range 1–5 months). There were no major intraoperative complications or primary graft failure, with one peripheral graft detachment that underwent a successful re-bubble at 1 week. All eyes had stable CAI implants and DMEK grafts remained clear at last follow-up with reduction in mean central corneal thickness (preoperative: 658±86 µm vs postoperative: 470±33 µm, p=0.005).ConclusionThis pilot study highlights a feasible approach of initial anterior segment reconstruction with CAI implantation, prior to DMEK, in eyes with significant anterior segment abnormalities such as iris damage or extensive peripheral anterior synechiae and corneal decompensation.

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‘Acute-angled bevel’ sign to assess donor lenticule orientation in ultra-thin descemet stripping automated endothelial keratoplasty

BMJ Case Reports ◽

10.1136/bcr-2018-227927 ◽

2019 ◽

Vol 12 (2) ◽

pp. e227927 ◽

Cited By ~ 2

Author(s):

Jeewan S Titiyal ◽

Manpreet Kaur ◽

Farin Shaikh ◽

Aafreen Bari

Keyword(s):

Optical Coherence Tomography ◽

Anterior Segment ◽

Acute Angle ◽

Optical Coherence ◽

Endothelial Keratoplasty ◽

Anterior Segment Oct ◽

Intraoperative Optical Coherence Tomography ◽

Congenital Hereditary Endothelial Dystrophy ◽

Graft Insertion

A 6.5-year-old boy with congenital hereditary endothelial dystrophy underwent clear corneal ultra-thin descemet stripping automated endothelial keratoplasty (DSAEK). After graft insertion, it was difficult to assess graft orientation due to hazy cornea. Intraoperative optical coherence tomography (iOCT) showed a well-attached graft and the bevelled edge of donor lenticule made an acute angle with the overlying stroma. Postoperative anterior segment OCT confirmed the presence of acute-angled bevel sign. A wetlab experiment was performed with experimental corneoscleral tissues to confirm the findings. Donor lenticule was injected in the artificial chamber with stromal-side up as well as stromal side-down. ‘Acute-angled bevel sign’ was observed on iOCT in the experimental cases with stromal-side up. In inverse graft, the acute-angled bevel was not observed, instead the configuration was obtuse angled. Identifying the ‘acute-angled bevel sign’ on iOCT confirms correct graft orientation after unfolding and is extremely useful for hazy corneas and ultrathin DSAEK lenticules.

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