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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 192-193

Graft failure in a case of migrating dislocated Descemet membrane endothelial keratoplasty scroll


1 The Cornea Institute, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
2 Smt. Kanuri Santhamma Center for Vitreoretinal Diseases, L. V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission06-May-2020
Date of Acceptance07-Sep-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Anubha Rathi
The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1344_20

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  Abstract 


Keywords: Endothelial keratoplasty, graft dislocation, graft failure, graft migration


How to cite this article:
Chaudhary S, Rathi A, Takkar B, Taneja M, Kamra D. Graft failure in a case of migrating dislocated Descemet membrane endothelial keratoplasty scroll. Indian J Ophthalmol Case Rep 2021;1:192-3

How to cite this URL:
Chaudhary S, Rathi A, Takkar B, Taneja M, Kamra D. Graft failure in a case of migrating dislocated Descemet membrane endothelial keratoplasty scroll. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 29];1:192-3. Available from: https://www.ijoreports.in/text.asp?2021/1/2/192/312326




  Case Report Top


A 55-year-old male presented with low vision in left eye (LE) following complicated cataract surgery and pars plana vitrectomy with scleral fixated intraocular lens (SFIOL) implantation. LE showed corneal stromal edema with peripheral epithelial bullae, suggesting pseudophakic bullous keratopathy (PBK) along with a large peripheral iridectomy (PI) [Figure 1]. Descemet Membrane Endothelial Keratoplasty (DMEK) was planned, but while unfolding the ultra-thin DMEK scroll, it dislocated into the posterior segment. In continuum, an uneventful Descemet stripping automated endothelial keratoplasty (DSAEK) was performed. Ultrasound B scan on a postoperative day 1 revealed the dislocated DMEK scroll in vitreous cavity with surrounding vitreous exudates and no retinal detachment (RD) [Figure 2]. The patient was managed conservatively with oral steroids in conjunction with a retina surgeon. At 10 weeks of follow-up, vitreous cavity had cleared and corneal edema had reduced with a well attached DSAEK graft [Figure 2] and [Figure 3]. However, 4 months postoperatively, the patient reported with graft failure. The vitreous cavity remained clear at this visit [Figure 2]. The dislocated DMEK scroll had migrated to the AC and was abutting the DSAEK graft as seen clinically and on ultrasound biomicroscopy (UBM) [Figure 4] and [Figure 5].
Figure 1: Pre-operative clinical photograph of the LE showing corneal stromal oedema with peripheral epithelial bullae and a large temporal peripheral iridectomy. The sub conjunctival haptics of the scleral fixated IOL are seen

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Figure 2: Ultrasound B scan of LE on post-operative day 1 showing dislocated DMEK scroll (yellow arrow) surrounded with vitreous exudates (a) which considerably cleared at 10 weeks (b) and 4 months of follow up (c)

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Figure 3: Clinical photograph of the LE at 10 weeks of follow up showing minimal peripheral corneal oedema with a well attached DSAEK lenticule

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Figure 4: Clinical photograph of LE at 4 months of follow up showing failing DSAEK graft with stromal oedema, overlying epithelial bullae and the migrated DMEK scroll in the anterior chamber (yellow arrow) seen both in slit beam (a) and retro-illumination (b)

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Figure 5: Ultrasound Biomicroscropy (UBM) images of the LE at 4 months of follow up showing the rolled DMEK scroll (yellow arrow) in the anterior chamber abutting the DSAEK graft (yellow star)

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  Discussion Top


DMEK should be avoided in cases with poor iris-lens-vitreous scaffold. Only few cases of posterior dislocation of the DMEK scroll are reported in comparison to DSAEK lenticule dislocation possibly due to differing case selection.[1],[2],[3] Unlike long term complications reported with dislocated DSAEK lenticule, dislocated DMEK scroll has been seen to be innocuous till a period of one year.[1] Other surgeons have preferred retrieval of the DMEK scroll along with unfolding and re-bubbling of the same to the host cornea.[2]

The free migration of DMEK scroll in our case is probably related to its thin structure and absence of vitreous. Such mobile scrolls may lead to or escalate graft decompensation, which should be kept in mind while contemplating management.

Acknowledgement

Hyderabad Eye Research Foundation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vasquez-Perez A, Brennan N, Ayoub T, Allan B, Larkin DFP, da Cruz L. Descemet membrane endothelial keratoplasty (DMEK) graft dislocation into the vitreous cavity. Cornea 2019;38:173-6.  Back to cited text no. 1
    
2.
Helaiwa K, Januschowski K, Boden KT, Rickmann A. An unusual case of DMEK graft loss into the vitreous and its successful retrieval and survival. Case Rep Ophthalmol 2018;9:381-7.  Back to cited text no. 2
    
3.
Singh A, Gupta A, Stewart JM. Posterior dislocation of descemet stripping automated endothelial keratoplasty graft can lead to retinal detachment. Cornea 2010;29:1284-6.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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