Pupillary Abnormalities in Descemet Membrane Endothelial Keratoplasty After Nearly Full Tamponade

Abstract

Purpose: To describe the incidence, risk factors, and management of pupillary abnormalities after anterior chamber (AC) full air or gas tamponade in Descemet membrane endothelial keratoplasty (DMEK) without pupillary block. Methods: In this retrospective case series, clinical records of 25 patients (32 eyes) who underwent DMEK were reviewed for pupillary abnormalities and iris morphology. All patients had nearly full intracameral tamponade with air or 20% SF6 at the end of surgery without default air release postoperatively. Results: Pupillary abnormalities ranging from mild ovalization to mid-mydriasis were seen in 56% of the cases. These abnormalities were not related to morphometric changes in the iris volume, or in the iris dilator or iris sphincter muscle, but were probably due to posterior synechiae. Combining DMEK and cataract surgery increases by 5-fold the odds of developing this complication. Surgical revision of the posterior surface of the iris and synechiolysis reversed these pupillary abnormalities. Conclusions: Nonischemic pupillary abnormalities can be seen in patients with DMEK using a nearly full air/gas tamponade in the AC after surgery despite patent iridectomy especially when combined with cataract surgery. Ensuring complete mydriasis in the immediate postoperative period and a free-floating bubble in the AC above the inferior pupillary margin may reduce its incidence.

<p>Surgery-induced iris abnormalities after Descemet membrane endothelial keratoplasty and their impact on postoperative clinical outcomes</p>

“…On the other hand, Arnalich-Montiel et al reported nonischemic pupillary abnormalities in 18 out of 32 eyes (56%) after nearly full tamponade DMEK 7. Among those eyes, 10 (31%) had relatively severe changes, displaced or mid-dilated pupil resulting from posterior synechiae 7. While Arnalich-Montiel et al used intracameral air or long-lasting 20% SF 6 gas, we used only room air in our patients.…”

“…Second, since we did not use 3-mirror lens or dilatation for evaluation of iris posterior synechiae, we were not able to detect faint synechiae with almost normal pupillary shape. On the other hand, Arnalich-Montiel et al reported nonischemic pupillary abnormalities in 18 out of 32 eyes (56%) after nearly full tamponade DMEK 7. Among those eyes, 10 (31%) had relatively severe changes, displaced or mid-dilated pupil resulting from posterior synechiae 7.…”

“…IOP elevation during the early postoperative period could induce ischemic pupillary changes, such as variants of Urrets-Zavalia syndrome 5,8. The frequency of surgery-induced iris abnormalities might be greater in DMEK (56–87%)6,7 than in DSAEK (12–37.5%) 9,10…”

“…Despite the remarkable visual recovery, a major post-DMEK complication is graft detachment, which may require rebubbling. Other unfavorable events, such as intraocular pressure (IOP) elevation, graft failure, immune rejection, cystoid macular edema, and iris abnormalities, have been reported 4–7…”

<p>Surgery-induced iris abnormalities after Descemet membrane endothelial keratoplasty and their impact on postoperative clinical outcomes [Letter]</p>

“…Secondly, it would have been more informative if the axial lengths of the eyes were mentioned as it is known that short axial lengths and iris damage are associated with iris posterior synechiae after DMEK 2. As the study population in this article is from Japanese eyes this becomes vital as Asian eyes are known to have short axial lengths and shallow anterior chamber depths.…”