Macrostriae and Descemet's membrane folds in the Descemet's stripping endothelial keratoplasty graft.

Descemet's stripping endothelial keratoplasty (DSEK) is a good alternative to penetrating keratoplasty in eyes with endothelial dysfunction due to faster healing, better refractive outcomes, absence of suture-related complications, and better wound security. The complications usually encountered after DSEK are graft dislocation, detachment, and rejection, secondary glaucoma, epithelial downgrowth, retrocorneal fibrous membrane, aqueous misdirection, cataract development and other minor non-vision threatening complications.[1-3] Wrinkles or folds after endothelial keratoplasty can cause poor visual outcome.[4] We report a case of macrostriae and Descemet's membrane folds in a DSEK graft.

A 63-year-old woman with a 4-year history of Fuchs' endothelial dystrophy in both eyes (OU) presented with floaters in her left eye (OS). She had undergone uncomplicated cataract surgery with posterior chamber intraocular lens implantation OS 3 years ago. One year later, she developed blurred vision in the same eye. Visual acuity was 20/200 OU. Increasing corneal edema was noted OS. The intraocular pressure (IOP) was 15 mm Hg in the right eye (OD) and 18 mm Hg OS. Central corneal thickness was 575 mm OD and 630 mm OS. Pseudophakic bullous keratopathy and progressive Fuchs’ dystrophy OS was diagnosed and DSEK OS was performed.

The DSEK was performed under monitored local anesthesia. The cornea was measured and the graft size was marked with gentian violet. The donor corneal lenticule was prepared using a Moria automated lamellar therapeutic keratoplasty (ALTK) microkeratome head with a 300-µm-depth blade and a Moria artificial anterior chamber maintainer (Moria, Doylestown, PA, USA). After excision of the anterior corneal lamella, a small “S” mark was made on the stromal surface with a sterile gentian violet pen to identify the correct orientation of the graft. The posterior lamellar tissue was then punched out from the endothelial side by using a mean 8 mm Hanna trephine donor punch (Moria). A superior scleral tunnel incision was made and the anterior chamber (AC) was filled with viscoelastic (Healon; Advanced Medical Optics, Santa Ana, CA, USA) and a reverse Sinskey hook was used to scour the host endothelium and Descemet's membrane along the circumference corresponding to the epithelial trephine mark. A Melles stripper (DORC, Zuidland, and The Netherlands) was used to carefully remove the diseased endothelium and Descemet's membrane and the specimen was submitted for pathological evaluation. A side port was made opposite the corneal wound to use the Busin glide to insert the graft. Four paracentral full-thickness venting incisions were made on the recipient cornea with a diamond blade. The scleral tunnel wound was then enlarged to about 4.5 mm and the viscoelastic was removed with irrigation and aspiration. The corneal button was mounted endothelial side up into a Busin glide which was then inverted and the graft was placed into the AC. An air bubble was then injected under the graft and the interface fluid was drained from the previously placed corneal incisions. A 100% air bubble was introduced in the AC and was maintained for approximately 10 minutes to ensure graft adhesion, after which air fluid exchange was performed leaving an approximate 40% air bubble.[4] To prevent pupillary block, cycloplegic drops were instilled. After subconjunctival and topical medications were administered, an eye patch was placed and patient was instructed to lie face up as much as possible.

On the first postoperative day, visual acuity OS was 20/400 and IOP was 15 mm Hg. There was a 35% air bubble in the AC with trace cells. The DSEK graft had few folds with irregular edema. Patient was treated with topical prednisolone acetate 1% and sodium chloride 5% ointment. One month after surgery, best corrected visual acuity was 20/200 in OS and eye examination revealed superficial punctate keratitis and Descemet's membrane folds in the DSEK button. Central corneal thickness was 587 mm OD and 749 mm in OS. She was treated with topical prednisolone acetate 1%, sodium chloride 5% ointment and preservative free tears. At the 34-month follow-up visit, she complained of progressive blurring of vision OU. Best corrected visual acuity was 20/80 OD and 20/100 OS. Eye examination revealed stable Fuchs’ dystrophy in the OD. The DSEK button in OS was irregularly contoured, with macrostriae in the graft and large Descemet's folds in the visual axis [Figure 1a]. There were no signs of anterior segment inflammation OS. She underwent a repeat DSEK in the OS. Histopathology revealed Descemet's membrane folds and severe endothelial atrophy [Figure 1b]. Postoperatively, she was put on frequent topical prednisolone acetate 1%, besifloxacin and erythromycin ointment. At the 4-month follow-up visit, visual acuity was 20/50 OS and the 2nd DSEK graft was clear without edema or macrostriae [Figure 1c].

Figure 1

(a) Slit-lamp photograph of left eye showing the macrostriae in pupillary area. (b) Microphotograph of failed DSEK graft showing folds in Descemet's membrane and endothelial atrophy (Hematoxylin and Eosin stain). (c) After 4 months of surgery, DSEK graft was clear

The most common reasons for failure of DSEK are endothelial cell loss and stromal edema.[5] In a study by Letko and associates, of the 1050 primary DSEKs, 37 eyes (3.5%) required repeat endothelial keratoplasty (REK).[4] The reasons for repeat graft were graft folds in the pupillary area (n = 25, 2.7%) leading to unsatisfactory vision, and endothelial decompensation (0.8%). Visual acuity improved from 20/60 before the REK to 20/30 later.[4] It was felt that thicker endothelial grafts and a mismatch between the donor and recipient corneal curvatures might be the cause for formation of these folds. Mean central corneal thickness in all eyes with poor vision was 809 mm (range 642–938 mm) pre-operatively and it was 678 mm (range 571–801 mm) after DSEK.[4]

The patient described in our report developed macrostriae and large Descemet's membrane folds in the DSEK graft in the pupillary area. The persistence of an edematous and thick graft might be the reason for the development of the macrostriae and Descemet's membrane folds in our case. A repeat graft resulted in improved visual acuity. Macrostriae and Descemet's membrane folds in the pupillary area can impair visual acuity and also may be a reason for graft failure. Though a thick graft was considered as the reason for the formation of these folds, long-term follow-up data from larger studies are required to know the reasons for development of this complication.