Anterior segment optical coherence tomography enables repeat Descemet Membrane Endothelial Keratoplasty instead of penetrating keratoplasty in a patient with a prominent corneal opacity following DMEK failure: a case report

Englmaier, VA; Bobe, S; Rolf, N; Kriegel, MF; Barth, P; Eter, N; Baydoun, L

Zusammenfassung

BACKGROUND - CASE PRESENTATION - CONCLUSION; Persistent corneal edema in eyes with endothelial dysfunction, such as graft failure, may lead to severe corneal opacification obscuring deeper ocular structures. In such cases, penetrating keratoplasty (PKP) has traditionally been preferred over posterior lamellar keratoplasty techniques to remove the edematous and opaque corneal tissue and replace it with a clear full-thickness graft.; A 48-year-old woman was referred for PKP one year following primary Descemet Membrane Endothelial Keratoplasty (DMEK) failure in the left eye. As slit-lamp biomicroscopy showed progressive corneal edema with marked corneal opacification, the patient was scheduled for PKP. However, on the day of surgery, an anterior segment optical coherence tomography (AS-OCT) revealed a dense subepithelial hyperreflective layer anterior to the hypodense corneal stroma, corresponding to the opacified tissue. Given the suspected interface between the two layers, the surgical strategy was changed to anterior lamellar keratectomy combined with repeat DMEK. Intraoperatively, the fibrotic tissue could be separated from the underlying, relatively clear cornea so that DMEK could be performed in the same session. Six weeks postoperatively, best-corrected visual acuity (BCVA) had improved from counting fingers to 20/40 (0.5), and AS-OCT-based pachymetry had decreased from 1200 µm to 470 µm.; Long-standing edema due to endothelial dysfunction may induce advanced corneal opacification, implying that PKP may be required to fully restore vision. Preoperative AS-OCT may be useful in such cases to distinguish separable subepithelial fibrosis from stromal involvement. Hereby the less invasive DMEK procedure may be performed while avoiding full-thickness transplantation with its associated complications.