|Year : 2022 | Volume
| Issue : 1 | Page : 64-65
Late-onset spontaneous Descemet's membrane detachment in penetrating keratoplasty - A case report
Revathi Rajaraman, Prabhu Vijayaraghavan, Arjun Velayudhan Nair
Department of Cornea and Refractive Services, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India
|Date of Submission||17-Jun-2021|
|Date of Acceptance||01-Sep-2021|
|Date of Web Publication||07-Jan-2022|
Dr. Arjun Velayudhan Nair
Department of Cornea and Refractive Services, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
We present a case of acute graft edema due to late-onset Descemet's membrane detachment (DMD) in a penetrating keratoplasty done two decades ago for keratoconus. A 48-year-old male presented with defective vision and redness in the right eye. The absence of the anterior chamber (AC) inflammation, keratitic precipitates, and the presence of glistening reflex in the AC, with a double contour along the inferotemporal graft host junction, suggested an acute hydrops in the graft. An anterior segment optical coherence tomography (ASOCT) confirmed DMD with the absence of an obvious tear. In the region of the double contour, a lamellar flap/fold of DM beyond the graft host junction (GHJ) but within the detachment and stroma was noted. Descemetopexy with intracameral sulfur hexafluoride gas and compression sutures along the region of the double contour restored graft clarity and vision. A DMD should be considered as a possible cause of acute edema and can be often misdiagnosed as graft rejection.
Keywords: Descemet's membrane detachment, descemetopexy, keratoconus, penetrating keratoplasty
|How to cite this article:|
Rajaraman R, Vijayaraghavan P, Nair AV. Late-onset spontaneous Descemet's membrane detachment in penetrating keratoplasty - A case report. Indian J Ophthalmol Case Rep 2022;2:64-5
|How to cite this URL:|
Rajaraman R, Vijayaraghavan P, Nair AV. Late-onset spontaneous Descemet's membrane detachment in penetrating keratoplasty - A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 28];2:64-5. Available from: https://www.ijoreports.in/text.asp?2022/2/1/64/334899
Penetrating keratoplasty (PKP) was the mainstay of treatment for advanced keratoconus (KC) up until a few decades ago. Graft edema in PKP may be due to rejection, failure, and infections. Acute-onset edema can also occur due to partial or total detachment of the Descemet's membrane (DM) in the graft. A late-onset Descemet's membrane detachment (DMD) should be considered as one of the etiologies in post-PKP graft edema. We present a case of late-onset DMD in a 21-year-old graft, initially managed as a presumed rejection episode. On confirmation with the anterior segment optical coherence tomography (ASOCT), DMD was successfully managed with pneumatic descemetopexy with gas and compression sutures.
| Case Report|| |
A 48-year-old known keratoconus patient with a history of penetrating keratoplasty (PKP) 21 years ago in the left eye (LE) presented with redness, pain, and defective vision of acute-onset. The patient gave no history of prior episodes of graft rejection. There was no recent history of trauma or eye rubbing preceding defective vision. On examination, his best-corrected visual acuity (BCVA) was 6/6 in the right eye (RE) and 1/60 in the LE. A slit-lamp examination of the LE showed diffuse and circumcorneal congestion, microcystic and stromal edema of the graft, the anterior chamber (AC) was formed but further details were not visualized due to edema. The RE showed a steep cornea with an apical scar, the rest of the anterior and posterior segments were within normal limits.
The patient was initially treated as a case of presumed acute graft rejection and was referred to us as the condition failed to improve. As there were no keratitic precipitates, the minimal anterior chamber reaction, and glistening reflex within the AC, and a double contour at the inferotemporal graft host junction (GHJ), we suspected acute hydrops in the graft [Figure 1]a. The ASOCT (Swept Source DRI OCT Triton; Topcon Medical Systems Inc, Topcon, Tokyo, Japan) confirmed the total DMD of the graft with no tears [Figure 2]b. The ASOCT in the region of the double contour of GHJ (inferotemporal), a tongue-shaped lamellar separation/fold in DM was apparent within the DMD beyond the GHJ [Figure 2]a. The patient was advised pneumatic descemetopexy with compression sutures. He underwent DM reposition with intracameral 20% sulfur hexafluoride (SF6) gas injection and a peripheral surgical iridectomy. The compression sutures were taken through the inferior and temporal quadrant of the GHJ. A tapering dosage of dexoren S (dexamethasone 0.1% + chloramphenicol 0.5%, Indoco Remedies Ltd., Mumbai, Maharashtra, India) eye drops along with 5% hypertonic saline drops (Hypersol—5, Jawa Pharma, India) was started. On follow-up in the immediate postoperative period, the corneal edema decreased, the clarity improved, and the DM appeared apposed in slit-view [Figure 1]b, [Figure 1]c, [Figure 1]d. Serial post-op ASOCT confirmed the reattachment of the DM and reduction in corneal edema [Figure 3]. The visual acuity improved once the bubble got completely absorbed. The patient had a short spike in the intraocular pressure and was suspected to have a steroid response which was managed with topical 0.5% timolol (Glucomol, Allergan India Pvt LTD, MP, India) eye drops. On his final follow-up 3 months later, the Uncorrected visual acuity (UCVA) was 4/60 improving to 6/36 (−7 D sphere −3D cylinder at 30°) in the LE.
|Figure 1: Diffuse illumination slit-lamp view showing microcystic and stromal edema extending from the edge to the edge in the graft, a double contour in the inferotemporal graft host junction (black arrowheads) (a) postoperative diffuse image showing clear graft with compression sutures and gas bubble filling half of AC (b) slit-view showing apposed DM and intracameral gas in situ with temporal peripheral iridectomy (c). Two months post-descemtopexy, the graft is clear, sutures in situ, iris details and lens are clearly seen, scaring with a resolution of a double contour along the inferotemporal GHJ (blue arrow) (d)|
Click here to view
|Figure 2: ASOCT through temporal graft host junction (GHJ) showing DMD with the extension of the wedge-shaped region beyond the GHJ and a tongue-shaped lamellar flap within the wedge (arrowhead), a red-free image of line scan across temporal graft host junction (a). ASOCT of the nasal edge of the graft with detached and folded DM with no tear up to GHJ, red-free image of line scan across the nasal graft edge (b)|
Click here to view
|Figure 3: ASCOT taken at the time of presentation showing total DMD across the graft with no tear (a) ASOCT take 1-week post-descemetopexy showing attached DM and reduction in stromal edema (b) ASOCT taken 3 weeks post-descemetopexy, edge to edge view; both GHJ are seen with well-apposed DM and compact stroma. Stretched and steep host cornea beyond the graft seen on either side (c)|
Click here to view
| Discussion|| |
The occurrence of the spontaneous detachment of the DM in the graft is sparsely reported. Corneal edema in the graft occurs due to acute rejection, decompensation, and graft failure. In the former, it is of sudden onset. DM detachment should be considered as one of the differential diagnoses in acute-onset graft edema. An ASOCT helps in identifying post-graft edema due to partial or total DMD. A late-onset DMD in a graft has been reported in the second decade,, even as late as the fourth decade after surgery. Several hypotheses have been postulated to explain the cause of late DMD in grafts. Gorski et al. suggested mechanical traction due to stretching and progressive ectasia of the graft as the possible cause. Formation of a retro corneal membrane with traction on the Descemet's and subsequent detachment was also considered by the same author. The steepening of the GHJ is commonly seen in post-keratoconus patients compared to other indications of PKP. A significant change was noted after the first decade of surgery in KC eyes. The weak anchoring of the pre-Descemet's layer, as well as the difference in the elasticity of DM and posterior stroma, can predispose to the detachment on stretching. A similar pattern of detachment in the Descemet's and deep stroma with adjacent thinning and ectasia of the host was evident in the ASOCT of our case as well. The DM detachment was evident slightly beyond scarred GHJ as shelving into the adjacent deeper layer of the host in the temporal and inferior quadrants. A similar occurrence was also described by Gorski et al. and Ezra et al. with a wedge of detachment extending beyond GHJ with no apparent tears in ASOCT in their respective case reports. In our case, the DM detachment being in the inferior quadrant and along an uneven scarred GHJ, to prevent recurrence of the detachment once the tamponade becomes weak after the absorption of gas, compression sutures were applied. The compression sutures were applied along these quadrants to enhance the apposition of the deep layers. The suture descemetopexy probably prevented immediate recurrence of DMD on the absorption of gas which was not uncommon in the previous reports.
| Conclusion|| |
In conclusion, DMD in the graft should be considered as a differential in acute graft edema. A high index of suspicion should be maintained as it may be misdiagnosed as acute rejection. An ASOCT helps to identify DMD, early recognition improves chances of graft survival and reposition with pneumatic descemetopexy.
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|| |
D'Souza S, Solanki N, Sushma KR, Solanki P. Late onset Descemet's membrane detachment 20 years after penetrating keratoplasty. Indian J Ophthalmol 2017;65:621-3.
Gorski M, Shih C, Savoie B, Udell I. Spontaneous descemet membrane detachment 20 years after penetrating keratoplasty for keratoconus. Cornea 2016;35:1023-5.
Nahum Y, Gal-Or O, Dadon J, Greenbaum A, Israeli D, Melles GRJ, et al
. Spontaneous descemet membrane detachment after penetrating keratoplasty-Clinical presentation and outcome of air/gas descemetopexy. Cornea 2020;39:1499-502.
Hasan SM, Jakob-Girbig J, Pateronis K, Meller D. Partial descemetorhexis for delayed Descemet membrane detachment following penetrating keratoplasty, suggestion of a pathomechanism. Am J Ophthalmol Case Rep 2021;22:101077.
Raecker ME, Erie JC, Patel SV, McLaren JW, Hodge DO, Bourne WM. Long-term keratometric changes after penetrating keratoplasty for keratoconus and fuchs endothelial dystrophy. Am J Ophthalmol 2009;147:227-33.
Kit V, Kriman J, Vasquez-Perez A, Muthusamy K, Thaung C, Tuft S. Descemet membrane detachment after penetrating keratoplasty for keratoconus. Cornea 2020;39:1315-20.
Ezra DG, Mehta JS, Allan BD. Late corneal hydrops after penetrating keratoplasty for keratoconus. Cornea 2007;26:639-40.
[Figure 1], [Figure 2], [Figure 3]