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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 237-239

Interface fluid: A rare complication of superficial anterior lamellar keratoplasty

Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission02-May-2020
Date of Acceptance15-Dec-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Prof. Namrata Sharma
Department of Ophthalmology, Cataract, Cornea and Refractive Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1275_20

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Superficial anterior lamellar keratoplasty (SALK) is a useful therapeutic modality to treat anterior and mid-stromal corneal opacities due to various pathologies including trachoma. The interface created during the surgery due to host and donor stroma-to-stroma apposition can be associated with potential complications that can affect its final surgical outcome. Collection of fluid in the interface after sutureless SALK has, rarely, if ever been reported. A 62-year-old man with bilateral pseudophakia and trachomatous keratopathy underwent microkeratome and fibrin-glue-assisted SALK for anterior stromal opacity in the left eye with an improvement of visual acuity to 6/18. Interface fluid was noted 1 week after the surgery which progressed to appear like a cyst subsequently. The visual acuity declined to 3/60. The fluid was drained and graft sutured under the guidance of intraoperative optical coherence tomography. No recurrence was noted till 3-months follow-up and the visual acuity resumed to 6/18.

Keywords: Corneal opacity, corneal stroma, fibrin glue, interface, SALK

How to cite this article:
Agarwal R, Bafna RK, Shakkarwal C, Sharma N. Interface fluid: A rare complication of superficial anterior lamellar keratoplasty. Indian J Ophthalmol Case Rep 2021;1:237-9

How to cite this URL:
Agarwal R, Bafna RK, Shakkarwal C, Sharma N. Interface fluid: A rare complication of superficial anterior lamellar keratoplasty. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2022 Dec 5];1:237-9. Available from: https://www.ijoreports.in/text.asp?2021/1/2/237/312322

Superficial anterior lamellar keratoplasty (SALK) is a useful microkeratome-assisted therapeutic procedure for replacement of anterior to mid-stromal corneal opacities.[1],[2] A graft-host interface created during this procedure has been associated with various complications including infection, rejection, hemorrhages, haze, residual debris, epithelial ingrowth, recurrence of primary disease, and sterile keratitis.[1]

Presently, we describe a case of interface fluid accumulation after sutureless SALK that appeared like a cyst and its management with the aid of real-time intra-operative optical coherence tomography (i-OCT, OPMI LUMERA 700 and RESCAN 700, Carl Zeiss, Germany).

  Case Report Top

A 68-year-old systemically healthy man with bilateral trachomatous keratopathy and pseudophakia presented with an uncorrected visual acuity (UCVA) of 2/60 (refraction was not possible due to corneal haze), decompensated cornea, diffuse anterior stromal haze and a linear full-thickness central corneal scar (history of repaired post-traumatic corneal perforation in childhood) OD [Figure 1]; BCVA of 3/60, diffuse anterior stromal scarring and spheroidal degeneration involving visual axis and keratometry of 37.6D and 44.5D at 171° OS [Figure 1] and normal intraocular pressure and B-scan ultrasonography OU. Anterior segment optical coherence tomography (ASOCT) demonstrated a corneal thickness and anterior stromal hyperreflectivity of 746 μm and 112 μm; and 474 μm and 147 μm OD and OS respectively and thickened Descemet membrane with undulations suggestive of early endothelial decompensation OS [Figure 1]. Specular microscopy could not be captured OU. Penetrating keratoplasty and SALK were planned for OD and OS respectively. Due to long waiting list for optical-grade donor tissues, SALK was undertaken first. After obtaining written informed consent, a 200 μm thick and 9 mm large host bed and donor flap (non-optical grade) were prepared using a size '0' microkeratome head (Moria Surgical, Antony, France) under peribulbar anesthesia. The host bed was rinsed thoroughly with balanced salt solution (BSS) following which donor flap was reposited, its anterior surface massaged, fibrin glue (Tisseel VH, Baxter, Deerfield, IL) applied at margins of the graft host junction (GHJ) and soft bandage contact lens (BCL, 14 mm, Bausch and Lomb, PureVision 2, USA) placed.
Figure 1: Clinical and ASOCT images showing decompensated cornea OD (a-b), spheroidal degeneration in visual axis OD (c-d) and diffuse anterior stromal haze OU

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The surgery was uneventful and postoperatively moxifloxacin––0.5%, prednisolone phosphate––1%, and carboxymethylcellulose––0.5% were administered 4 times/day. Till 3rd postoperative day, GHJ was well-apposed with clear interface and UCVA-6/18. One-week later, small amount of interface fluid [Figure 2] and graft edema (360 μm) were noted and managed conservatively. One-week further, dramatic increase in interface fluid appearing like a single cystic cavity, graft edema with an elevated GHJ on the temporal side, not associated with epithelial defect or raised intraocular pressure, and UCVA of 3/60 were noted. [Figure 2]. The patient was not using any anti-glaucoma medications and the BCL was also in situ at the time of fluid accumulation.
Figure 2: Mild interface fluid and haze and graft edema (360 μm) on 7th postoperative day (a-b) and fluid appearing like a cyst with hazy and edematous graft on 14th postoperative day (c-d)

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Interface fluid was drained under the guidance of i-OCT after denuding the temporal 3'0 clock GHJ and performing unidirectional, from nasal to temporal, superficial strokes on the graft with an iris repositor [Figure 3]. Following complete drainage, 16 '10-0' monofilament sutures were placed to secure the graft in place. The same postoperative regime was continued as before. There was no recurrence of fluid with a UCVA of 6/18 till 3-months follow up [Figure 4]. The graft resumed its original thickness of 200 μm.
Figure 3: Appearance of interface fluid on real time OCT (a); temporally elevated graft host junction (b); denudation (c) and drainage (d) of interface fluid with the aid of iris repositor; intraoperative appearance after complete drainage and suturing (e-f)

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Figure 4: Postoperative appearance at 3-months follow up showing well-apposed and clear host and graft. Note resumption of the graft thickness to 200 μm

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  Discussion Top

The present complication appeared like a cyst due to the closed nature of the fluid accumulation with no appreciable inflow or outflow tract.[3],[4] The source of fluid, however, remains elusive. We speculated that trachomatous keratopathy-induced weak adhesions and microkeratome-cut induced geometric mismatch between donor and recipient curvatures created a potential space between them.[5] Fluid collected in this space due to osmotic retention of tear film or aqueous fluid induced by accumulated metabolic waste, fibrin glue and debris in the interface or by poorly functioning host endothelium (indicated by thickened Descemet membrane in affected eye and increased corneal thickness in other eye). The medications collected underneath the BCL and aqueous fluid entering through trabecular meshwork could have also contributed to fluid collection.[6] A tight fit BCL might have also caused hypoxia in an already compromised endothelium and lead to fluid accumulation in a potential space. We believe that cytopathological examination of this fluid, although not undertaken presently, might have provided more insight into its pathogenesis. Meticulous clinical examination and review of intra-operative notes ruled out presence of retained viscoelastic substance in the interface.[5],[6] Stromal graft rejection which may present with a similar stromal edema has seldom been reported after SALK.[7],[8],[9]

Similar kind of fluid accumulation has also been reported after other lamellar keratoplasty procedures such as deep anterior lamellar keratoplasty (DALK) and Descemet stripping endothelial keratoplasty.[3],[4],[9] In these cases, however, a connection between the AC and the interface is usually noted and the aqueous humor is the usual source of fluid. As interface fluid could compromise graft clarity and lead to textural interface opacity, early management was mandatory.[10] Various methods of managing interface fluid include surgical drainage on slit-lamp or under microscope, graft exchange, or PKP.[5],[9] While waiting for spontaneous resolution can be attempted in cases with minimal fluid, a progressive increase in fluid content and compromised graft clarity necessitated surgical drainage in our case. DALK was not required as residual host stromal bed appeared clear. Graft exchange with a thinner graft or PKP were not attempted due to unknown effect of edematous host on graft-host apposition and inherent risks of open-sky procedure respectively.

Localized deroofing of cyst at the most elevated part of GHJ undertaken for its drainage in our case was similar to creating a new outflow tract by giving stab incisions performed for endothelial keratoplasties.[3],[4],[5] Our presumption that poor tensile strength of fibrin glue gave way to fluid collection in an already compromised endothelium proved appropriate as the graft remained clear and well-apposed with no future recurrences after suturing it to the host.[2] Also, placing 16 sutures aided in equal distribution of compressive forces as it could not be clearly determined if the localized elevation of GHJ in our case was a cause or a result of interface fluid accumulation.

  Conclusion Top

To conclude, eyes with suspicious endothelial function may require a sutured SALK in the primary sitting to prevent accumulation of interface fluid appearing like a cyst. Post sutureless SALK, fluid drainage with graft suturing may be tried before undertaking any repeat keratoplasty procedure.


We thank our Institute for allowing us to continue with our research work.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Patel AK, Scorcia V, Kadyan A, Lapenna L, Ponzin D, Busin M. Microkeratome-assisted superficial anterior lamellar keratoplasty for anterior stromal corneal opacities after penetrating keratoplasty. Cornea 2012;31:101-5.  Back to cited text no. 1
Agarwal T, Bandivadekar P, Sharma N, Sagar P, Titiyal JS. Sutureless anterior lamellar keratoplasty with phacoemulsification. Cornea 2015;34:615-20.  Back to cited text no. 2
Acar BT, Acar S. Triple anterior chamber after deep anterior lamellar keratoplasty. Ann Clin Case Rep 2016;1:1103.  Back to cited text no. 3
Basak SK, Basak S. Complications and management in Descemet's stripping endothelial keratoplasty: Analysis of consecutive 430 cases. Indian J Ophthalmol 2014;62:209-18.  Back to cited text no. 4
[PUBMED]  [Full text]  
Turaka K, Rapuano CJ, Eagle RC Jr, Abazari A, Hammersmith KM. Macrostriae and Descemet's membrane folds in the Descemet's stripping endothelial keratoplasty graft. Oman J Ophthalmol 2011;4:90-1.  Back to cited text no. 5
[PUBMED]  [Full text]  
Passani A, Sframeli AT, Loiudice P, Nardi M. Late spontaneous resolution of a double anterior chamber post deep anterior lamellar keratoplasty. Saudi J Ophthalmol 2017;31:58-60.  Back to cited text no. 6
Miyakoshi A, Ozaki H, Otsuka M, Hayashi A. Efficacy of intraoperative anterior segment optical coherence tomography during Descemet's stripping automated endothelial keratoplasty. ISRN Ophthalmol 2014;2014:562062.  Back to cited text no. 7
Watson SL, Tuft SJ, Dart JKG. Patterns of rejection after deep lamellar keratoplasty. Ophthalmology 2006;113:556-60.  Back to cited text no. 8
Sharma N, Agarwal R, Jhanji V, Bhaskar S, Kamalakkannan P, Nischal KK. Lamellar keratoplasty in children. Surv Ophthalmol. 2020;65:675-90.  Back to cited text no. 9
Juthani VV, Goshe JM, Srivastava SK, Ehlers JP. Association between transient interface fluid on intraoperative OCT and textural interface opacity after DSAEK surgery in the PIONEER study. Cornea 2014;33:887-92.  Back to cited text no. 10


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


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