Descemet Membrane Detachment After Penetrating Keratoplasty for Keratoconus

Abstract

Purpose: To describe risk factors, management and outcome of delayed Descemet membrane (DM) detachment following penetrating keratoplasty (PK) for keratoconus.Methods: We report seven eyes and combine this data with seven previous case reports identified by a search of PubMed.Results: DM detachment occurred at a median of 25 years (range, 7 to 33 years) following PK. One individual had bilateral detachments. There was typically mild ocular discomfort accompanied in some cases by a rapid onset of visual blur. Cases were often treated for allograft rejection before a DM detachment was suspected and confirmed by optical coherence tomography. Detachments were limited to the donor tissue in eleven eyes, but a DM break was identified at the time of onset in only two eyes. Thinning of the host corneal rim with ectasia was reported in eight eyes (57%). In three eyes the detachment resolved spontaneously, but in two eyes a detachment was still present at 12 months. Gas tamponade to reattach the DM was performed in nine eyes and was effective in five eyes.Five eyes had a repeat PK or endothelial keratoplasty. Histology showed fibroblastic proliferation on the stromal surface of the folded DM. Conclusion:The cause for DM detachment many years after PK is unknown, although progressive thinning of the host cornea and secondary graft ectasia may be implicated. Gas tamponade can be effective, but a repeat keratoplasty may be necessary. DM detachment should be included in the differential diagnosis for late onset corneal oedema after PK.

Management of Late Descemet's Membrane Detachment After Penetrating Keratoplasty in Keratoconus

“…8,9 However, in recent AS-OCT examinations, a DM break was identified only in a subset of patients (4 of 14 eyes). 4 Several modalities for the treatment of late DMD have been proposed. 2–7…”

“…A special situation is DMD occurring late after penetrating keratoplasty (PK): Several case reports and series have described patients with a history of PK who developed a sudden or insidious visual deterioration due to DM detachment. [2][3][4][5][6][7][8][9][10][11] Kit et al 4 described DMD in 14 cases, in which PK had been performed at a median of 25 years ago, and found that DMD was often misdiagnosed as late graft rejection because the presentation with (sub)acute onset of corneal edema can be similar.…”

Late-onset spontaneous Descemet's membrane detachment post penetrating keratoplasty in a patient with congenital glaucoma

“…Delayed-onset DMD has been reported following PKP for corneal ectasias such as keratoconus and pellucid marginal degeneration. [ 6 7 ] Other reports described it as acute hydrops with detectable breaks in DM using anterior segment OCT.[ 8 ] The mechanism of DMD following PKP for keratoconus is unclear. Some authors proposed the presence of a retro-corneal membrane along the graft–host interface that can cause mechanical detachment of DM.…”

“…[ 6 ] However, some cases require further intervention such as endothelial keratoplasty or regraft. [ 5 6 ] Our patient was treated successfully with air injection and the cornea was clear within 10 days following the procedure. However, the vision improved minimally due to advanced glaucomatous optic nerve damage and amblyopia.…”

“…[ 3 4 ] However, in the absence of trauma, DMD years after penetrating keratoplasty (PKP) is rare. [ 5 6 ] We report the presentation and management of late-onset spontaneous DMD post-PKP and cyclophotocoagulation in a patient with congenital glaucoma.…”