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

Abstract

The purpose of this study was to describe the feasibility of Descemet membrane endothelial keratoplasty (DMEK) as a treatment modality for spontaneous detachment of DM (DMD) decades after penetrating keratoplasty (PK) for keratoconus. Methods:We describe the clinical characteristics and therapeutic surgical approach in 6 eyes of 5 patients with DMD. Clinical images, anterior segment optical coherence tomography scans, and histological findings are presented.Results: Mean age of patients at time of diagnosis was 60 years (range 56-66 years). Mean interval between PK and occurrence of DM detachment was 36 years (range 29-45 years). In 4 of 6 eyes, air injections into the anterior chamber were initially attempted to reattach DM to the stroma but without long-lasting effect. Two eyes underwent repeat PK because of pronounced ectasia after long-standing DMD and stromal scars. DMEK was performed successfully in 4 eyes leading to an increase in visual acuity and a reduction in central corneal thickness. Electron microscopy showed abnormal vacuolar inclusions and collagenous material in the posterior nonbanded layer and a separation of the anterior banded layer from the posterior nonbanded layer. Conclusions:This case series provides evidence that DMEK is a viable option in eyes with spontaneous DM detachment after PK. Visual outcome is limited by the persisting high astigmatism in the ectatic cornea. Illustrated by a small series of patients, the results of DMEK in this condition are presented and new findings about the pathophysiology are given.

Surgical management of complicated Descemet’s membrane detachment in corneas without prior endothelial keratoplasty

“…However, one of the most important predisposing factors seems to be ectatic corneal disorders, which might lead to secondary graft ectasia characterized by inferior thinning of the graft-host junction and steep keratometry after one to three decades ("keratoconus recurrence") [ 23 ]. In our study, DMD involved the entire graft in most cases, which is consistent with previous reports [ 10 , 11 ], whereas rupture of DM was not a mandatory feature. DMD was limited to the host cornea in only one eye, which could be attributed to a small graft diameter (6.0 mm).…”

“…Air/Gas-Descemetopexy has proven to be a reliable method in the acute setting with high success rates for DMD after glaucoma or cataract surgery [ 1 , 2 ], whereas the complication risk, such as repeat detachment with rates up to 55% [ 12 ], and the visual outcome seem to be worse for DMD after PKP [ 10 , 12 ]. Variations of this procedure depend on the cause, such as additional descemetotomy to remove a hemorrhage or viscoelastics between DM and the overlying stroma and reduce the risk of repeat DMD.…”

“…Variations of this procedure depend on the cause, such as additional descemetotomy to remove a hemorrhage or viscoelastics between DM and the overlying stroma and reduce the risk of repeat DMD. Another study group recommended DMEK even for spontaneous DMD after PKP if Air/Gas-Descemetopexy is unsuccessful [ 10 ]. Nevertheless, both surgical procedures do not address the primary issue of the curvature anomaly after PKP and are more suitable for iatrogenic induced detachments after glaucoma or cataract surgery in non-ectatic corneas.…”

Descemet Membrane Detachment Triggered by Contrast-Enhanced Computed Tomography in a Patient with a History of Penetrating Keratoplasty for Keratoconus Treatment

“…The factors affecting the success of air tamponade remain unclear. Weller et al [ 4 ] examined histological changes using electron microscopy and proposed that migration of cells into the fissure between the anterior banded and posterior non-banded layers would occur if detachment persisted for a longer period. However, it is unclear whether duration of DM detachment affects the outcomes of air and gas tamponade [ 1 , 3 ].…”

“…Late-onset complications of PKP, such as endothelial loss, allograft rejection, progressive astigmatism associated with peripheral corneal thinning, and glaucoma requiring corticosteroid administration for the prevention of rejection, are well known. DM detachment after PKP for keratoconus has been reported recently [1‒4] and should be differentiated from acute rejection, as a complication that typically occurs 1–3 decades after surgery [2]. DM detachment is characterized by minor symptoms, such as pain and conjunctival redness without intraocular inflammation, and sudden onset.…”