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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 69-71

Late-onset Descemet's membrane detachment secondary to presumed interface fluid syndrome after uneventful deep anterior lamellar keratoplasty for keratoconus


1 Cornea and Refractive Surgery Services, Giridhar Eye Institute, Ernakulam, Kerala, India
2 Cataract and Glaucoma Services, Giridhar Eye Institute, Ernakulam, Kerala, India

Date of Submission19-Apr-2021
Date of Acceptance20-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Vinay S Pillai
Cornea and Refractive Surgery Services, Giridhar Eye Institute, Ernakulam, Kerala - 682 026
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_929_21

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  Abstract 


A forty-year-old male underwent an uneventful big-bubble deep anterior lamellar keratoplasty (DALK) for keratoconus in the right eye. Suture removal was attempted 15 months post-surgery and led to temporal graft host dehiscence that required resuturing of the graft. The patient presented 4 months later with increased intraocular pressure (IOP), graft edema, and nasal Descemet membrane detachment (DMD). IOP control with medication led to reduction and total resolution of DMD and a clear graft. We postulate that the DMD, in this case, was caused by a mechanism similar to the interface fluid syndrome (IFS) that occurs in post-laser in situ keratomileusis (LASIK) eyes and should be considered as a differential diagnosis for DMD following DALK.

Keywords: DALK, interface fluid syndrome post-DALK, keratoconus, late-onset DMD post-DALK, PISK


How to cite this article:
Galiyugavaradhan S, Pillai VS, Nair A. Late-onset Descemet's membrane detachment secondary to presumed interface fluid syndrome after uneventful deep anterior lamellar keratoplasty for keratoconus. Indian J Ophthalmol Case Rep 2022;2:69-71

How to cite this URL:
Galiyugavaradhan S, Pillai VS, Nair A. Late-onset Descemet's membrane detachment secondary to presumed interface fluid syndrome after uneventful deep anterior lamellar keratoplasty for keratoconus. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:69-71. Available from: https://www.ijoreports.in/text.asp?2022/2/1/69/334992



Descemet membrane detachment (DMD) can occur in intraocular surgeries and is commonly reported after cataract surgery.[1] It is often recognized in the immediate postoperative period. Though delayed or late-onset DMD is rare, it has been well-documented following penetrating keratoplasty.[2],[3],[4] A detailed literature search for reports on late-onset DMD post-deep anterior lamellar keratoplasty (DALK) surgery did not yield any results. To the best of our knowledge, we are reporting the first case of late-onset spontaneous DMD post an uneventful DALK surgery for keratoconus.


  Case Report Top


A 40-year-old male patient with bilateral keratoconus presented to our clinic for visual rehabilitation. At presentation, the best-corrected visual acuity (BCVA) was Counting Finger (CF) at 50 cm in the right eye (RE) and 6/9 in the left eye (LE). The cornea of the RE showed thinning with ectasia and Fleisher's ring. The cornea was clear in the LE. Keratoconus was confirmed in BE (both eyes) using corneal tomography (Oculyzer II, Alcon, USA). The RE had advanced keratoconus with the thinnest point being 285 microns. We decided to observe the LE and an uneventful big-bubble DALK was performed for RE without any micro- or macro-perforation of the host Descemet membrane (DM). The graft was clear with well-attached DM on the first postoperative day. The postoperative regime included moxifloxacin 0.5% eye drops (four times/day) for 2 weeks, lubricants (six times/day), and prednisolone 1% eye drops (six times/day, monthly, taper to once daily). The graft remained clear at the 6-month follow-up, but the intraocular pressure (IOP) was 27 mmHg. The IOP was controlled with a combination of brimonidine tartrate (0.2%) and timolol maleate (0.5%) eye drops, twice daily and the condition of the patient remained stable after this. Suture removal was done 15 months post-DALK in two sittings (eight alternate sutures/sitting) spaced 2 weeks apart. The graft host dehiscence occurred at the temporal graft host junction with separation of the temporal half of the graft from the host bed at the time of the second sitting of the suture removal. The host DM remained intact, and no micro- or macro-perforations were noted. The graft was resutured on the same day and remained clear with well-attached DM on the first postoperative day after resuturing. Prednisolone 1% acetate eye drops dosing was stepped up to six times/day with a monthly taper and antiglaucoma medications were continued. Four months after resuturing, the patient presented to the emergency with a drop in vision in the RE. No history of trauma was reported at any visit. The examination showed edema of the corneal graft and DMD in the superonasal area [Figure 1]a and [Figure 1]b. The IOP was 44 mmHg with a quiet anterior chamber. The patient was on prednisolone acetate 1% eye drops twice daily. The anterior segment optical coherence tomography (AS-OCT) confirmed the presence of DMD [Figure 1]c. The IOP was controlled with a combination of brimonidine tartrate (0.2%) and timolol maleate (0.5%) eye drops twice daily, dorzolamide (2%) eye drops three times daily, oral acetazolamide, and switching to loteprednol (0.5%) eye drops. The DMD reduced with a reduction in IOP, and the DM was totally attached with a clear graft [Figure 2]a, [Figure 2]b, [Figure 2]c and normal IOP at 3 weeks of follow-up. The patient was then maintained on loteprednol (0.5%) eye drops and a combination of brimonidine tartrate (0.2%) and timolol maleate (0.5%) eye drops. A year later, the graft remained clear with attached DM, well-controlled IOP, and BCVA of 6/9 in the RE.
Figure 1: Diffuse (a), slit (b), and AS-OCT (c) image of DMD in the superonasal area at presentation.

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Figure 2: Diffuse (a), slit (b), and AS-OCT (c) image of a clear graft with well-attached DM in the RE at 3 weeks of follow-up.

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  Discussion Top


DMD may be managed medically or surgically depending on its extent or severity. DMD after DALK has been reported in the immediate postoperative period and attributed to micro- or macro-perforations in the host DM.[5],[6] Retained host DM along with a functional endothelium in the donor cornea or an unrecognized type 2 bubble are other causes of DMD post-DALK.[5],[6] Our case underwent an uneventful big-bubble DALK for advanced keratoconus in the RE. Post-procedure, the patient developed elevated IOP which was managed medically. Transient elevation of IOP is common after DALK, but the incidence of de novo glaucoma is low.[7] Our case had to be maintained on a combination of brimonidine tartrate (0.2%) and timolol maleate (0.5%) eye drops twice daily to control IOP. The suture removal at 15 months resulted in the dehiscence of the graft host junction with the separation of the graft from the host the bed and needed resuturing. Though the dehiscence involved nearly the temporal half of the graft, the host DM remained intact and there was no aqueous leak or collapse of the anterior chamber. The reason for the dehiscence is unclear and probably due to excess force at the time of pulling the suture which may have caused traction. Resuturing the graft on the same day resulted in an excellent outcome with a clear graft and attached DM from the next day. Four months after resuturing, the patient had a vision drop due to corneal edema and nasal DMD associated with high IOP. The IOP rise can be attributed to the stepping up of the topical steroids after resuturing. Given the absence of any micro- or macro-perforations at the time of the two surgeries and the absence of any DMD in the immediate postoperative period, the reason for the late-onset DMD in our case remains to be explained. We postulate that late spontaneous DMD in our case is caused by a mechanism similar to the interface fluid syndrome (IFS) that occurs after laser in situ keratomileusis (LASIK).[8],[9],[10] Pressure-induced stromal keratitis (PISK) usually occurs in the early postoperative period of the LASIK, presenting as mild corneal edema with interface and stromal haziness secondary to high IOP. With persistent high IOP, commonly due to steroid response, accumulation of fluid in the interface occurs resulting in the lifting of the LASIK flap from its bed—the IFS. In our case too, similar to IFS, fluid from the graft edema due to the high IOP could have gained access to the potential space between the host DM and donor cornea resulting in the separation of DM. Our plan was to initially control the IOP and then address the DMD. Conversely, reduction in IOP leads to progressive reduction in the DMD too. Within 3 weeks of detecting the DMD and within a week of achieving good IOP control, the DMD resolved completely leaving a clear graft. Also, the separation of the graft from the host bed during suture removal may indicate poor healing of the graft host interface, which in turn may be the reason for the fluid to gain access into this potential space. Reduction and subsequent total resolution of the DMD to the lowering of the IOP favor our speculation that the mechanism of DMD in our case may be similar to IFS in post-LASIK eyes.


  Conclusion Top


To the best of our knowledge, this is the first case report of late-onset DMD after an uneventful DALK.

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.

Acknowledgment

Technical help- Mr Vineeth K, Mr Sanjay Louis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singhal D, Sahay P, Goel S, Asif MI, Maharana PK, Sharma N. Descemet membrane detachment. Surv Ophthalmol 2020;65:279-93.  Back to cited text no. 1
    
2.
Gorski M, Shih C, Savoie B, Udell I. Spontaneous descemet membrane detachment 20 years after penetrating keratoplasty for keratoconus. Cornea 2016;35:1023-5.  Back to cited text no. 2
    
3.
Lin J, Hassanaly S, Hyde RA, Brown J, Yoon D, Yu CQ. Late detachment of Descemet's membrane after penetrating keratoplasty for pellucid marginal degeneration. Am J Ophthalmol Case Rep 2019;13:151-3.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Lin X, Wu Y, Fu Y, Dai Q. Spontaneous reattachment of Descemet membrane detachment after deep anterior lamellar keratoplasty: A case report. Medicine (Baltimore) 2018;97:e0032.  Back to cited text no. 5
    
6.
Jinagal J, Singh T, Arya SK. Spontaneous attachment of detached Descemet membrane following deep anterior lamellar keratoplasty. Indian J Ophthalmol 2019;67:1698-9.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Huang OS, Mehta JS, Htoon HM, Tan DT, Wong TT. Incidence and risk factors of elevated intraocular pressure following deep anterior lamellar keratoplasty. Am J Ophthalmol 2016;170:153-60.  Back to cited text no. 7
    
8.
Tello A, Galvis V, Mendoza BF. LASIK Interface Complications: Pressure-induced Stromal Keratitis (PISK), Interface Fluid Syndrome (IFS) and Post-LASIK Edema-induced Keratopathy (PLEK). Int Ophthalmol Clin 2016;56:185-7. doi: 10.1097/IIO.0000000000000129. PMID: 27257731.  Back to cited text no. 8
    
9.
Unlu M, Hondur AM, Korkmaz S, Kumova D, Yuksel E. Pharmacologic management of pressure-induced stromal keratopathy after LASIK. Optom Vis Sci 2016;93:757-9.  Back to cited text no. 9
    
10.
Vasquez-Perez A, Aiello F, Muthusamy K, Tuft S. Urrets-Zavalia syndrome with interface fluid syndrome following laser in situ keratomileusis. Am J Ophthalmol Case Rep 2018;13:96-8.  Back to cited text no. 10
    


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