A 65-year-old woman was referred with postoperative persistent corneal edema and interface fluid superiorly without dislocation of the donor button after Descemet’s stripping automated endothelial keratoplasty (DSAEK). Slit lamp examination revealed the presence of fluid in the interface between donor and recipient button at the superior part of the cornea but the diagnosis was uncertain clinically due to significant corneal clouding. Anterior segment optical coherence tomography (AS-OCT) examination revealed donor graft dislocation behind the iris at the superior part of the lenticule. This case report demonstrates that donor graft partial dislocation behind the iris after DSAEK could be a potential cause of DSAEK failure. AS-OCT is a useful and noninvasive instrument for detecting the post-DSAEK complication especially in patients in which diagnosis is difficult due to significant corneal clouding.
Diagnosis of Donor Graft Partial Dislocation Behind the Iris After DSAEK with Anterior Segment OCT
From the Bascom Palmer Eye Institute (G-DK, TI, KD, S-HY), Cornea and External Diseases, Miami, Florida; and the Department of Ophthalmology (G-DK), Vardinoyannion Eye Institute of Crete, Crete, Greece.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to George D. Kymionis, MD, PhD, Institute of Vision and Optics, University of Crete, Medical School, Department of Ophthalmology, 71110 Heraklion, Crete, Greece.
Accepted: November 11, 2008
Posted Online: March 09, 2010
Descemet’s stripping automated endothelial keratoplasty (DSAEK) is a new treatment option of selective endothelial transplantation for endothelial dysfunction. It is a less invasive than penetrating keratoplasty (PKP) with more rapid visual recovery and better structural integrity.1–3
Several DSAEK complications have been described with graft detachment being the most common complication.1–6 Management of this complication that can potentially lead to graft failure involves repositioning of the graft (repositioning) and injection of an air bubble (rebubbling). Proposed etiologies of graft detachment include patient’s eye rubbing and poor donor/recipient tissue preparation.
We present a patient with corneal edema due to donor graft partial dislocation behind the iris, diagnosed by anterior segment optical coherence tomography (AS-OCT).
A 65-year-old woman with Fuchs’ endothelial dystrophy underwent DSAEK in the right eye for pseudophakic bullous keratopathy after cataract surgery. Preoperatively, the best-corrected visual acuity (BCVA) in this eye was 20/200. The operation was uneventful. On the first postoperative day, the patient had a pupillary block and a portion of the air bubble was removed. The pupil block glaucoma was resolved and intraocular pressure was controlled. During the postoperative period, persistent corneal edema without any evidence of donor button dislocation was observed. The pupil was fixed and dilated superiorly. No surgical intervention (air bubble injection in the anterior chamber) was performed due to the uncertain diagnosis and the previous pupillary block.
The patient was referred for graft failure after DSAEK with postoperative persistent corneal edema and interface fluid superiorly without dislocation of the donor button. Slit lamp examination revealed the presence of interface fluid between donor and recipient button at the superior part of the cornea but the diagnosis was uncertain clinically due to significant corneal clouding (Fig. 1). The pupil was fixed and dilated superiorly with possible diagnosis of Urrets-Zavalia Syndrome. An AS-OCT examination (Visante™ OCT, Model 1000, Carl Zeiss-Meditec, Dublin, CA) was performed showing a detachment of the donor button resembling a fluid cleft with partial dislocation of the donor tissue behind the iris (Fig. 2).
Figure 1. Slit Lamp Biomicroscopy Revealed Significant Corneal Clouding and Fixed-Dilated Pupil Superiorly.
Figure 2. Anterior Segment OCT (AS-OCT) Revealed Superior Donor Graft Partial Dislocation Behind the Iris After Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) [axis of OCT Scan:135° (superiorly) to 315° (inferiorly)].
Donor tissue dislocation and pupil block glaucoma have been reported as the most frequent complications after DSAEK.3–5 Several advancements and modifications of DSAEK techniques such as elimination of interface fluid from the donor–recipient junction, intraoperative peripheral iridotomies, and air bubble removal several minutes after the procedure have been proposed to decrease the incidence of these complications.6
In this case report, we present a patient with donor graft partial dislocation behind the iris after DSAEK diagnosed with AS-OCT. The patient was referred for primary donor graft failure, corneal edema, and interface fluid superiorly without dislocation of the donor button. The etiology of the graft failure was initially not identifiable due to significant corneal clouding. AS-OCT examination revealed donor graft dislocation behind the iris at the superior portion of the donor tissue. The patient had previous early postoperative pupillary block that was treated by air removal. Manipulations during this intervention could have potentially caused donor graft partial dislocation behind the iris. Early diagnosis is essential to avoid graft failure. AS-OCT could be a useful instrument for on early recognition and possible management of this complication, especially in such cases in which the visualization of the cornea is difficult with the slit lamp examination due to the corneal edema.
This case report demonstrates that donor graft partial dislocation behind the iris after DSAEK could be a potential complication after DSAEK; AS-OCT could be a useful noninvasive instrument for the early recognition and possible management of subtle graft detachments that are difficult to visualize at the slit lamp.
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