Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

Abstract

Purpose: To report how to manage a specific type of Descemet’s membrane (DM) rupture during manual DALK with a concurrent donor–recipient disparity of curvature. Methods: Case report of two patients that had DM rupture during manual DALK with a concurrent donor–recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a “DSEK autograft,” was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. Results: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). Conclusion: The existence of a donor–recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor–recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Deep anterior lamellar keratoplasty for corneal penetrating wounds

“…Its indications have broadened to include not only routine keratoconus, post-infectious leukoma, and stromal dystrophies, but also serious infective keratitis refractory to medical treatment, keratoconic eyes with history of previous hydrops, descemetocele, and keratoglobus. 5,[9][10][11][12][13][14] Several studies report good outcomes of DALK performed in eyes affected by keratoconus with history of corneal hydrops, demonstrating that the presence of a break into the DM is not an absolute contraindication for DALK. 9 Additionally, it has been also demonstrated that intraoperative unexpected DM ruptures may be mended with good results.…”

Rescue Technique to Solve Postoperative Refractory Double Anterior Chamber in Deep Anterior Lamellar Keratoplasty

“…The decision to use a 0.25-mm oversized donor might have played some role too. 8 This kind of double AC, refractory to rebubbling, can be solved by using our technique of anchoring sutures.…”

“…The decision to use a 0.25-mm oversized donor might have played some role too. 8 This kind of double AC, refractory to rebubbling, can be solved by using our technique of anchoring sutures. It is known that the recovery from persistent corneal edema due to second anterior chamber formation is a prolonged process.…”

Deep Anterior Lamellar Keratoplasty: Can All Ruptures Be Fixed?

“…Significant disparity of curvature between donor and recipient can lead to a persistent double anterior chamber and may necessitate surgical repair. 4,14,16 Two different types of disparity can occur; the recipient bed can be significantly flatter (Fig. 3A) or steeper (Figs.…”

“…These specific surgical techniques have previously been described in detail and published by our group. 4,14,16 Management of Uncommon DM Rupture Cases DM breaks occurring while inserting the needle or cannula into the stroma looking for a deep plane to inject air and attempt a BB (1 case) were managed by switching to a manual DALK without trying to attempt a pneumatic or viscodissection. At the end of the surgery, an air bubble was left in the AC.…”