Complications and management in Descemet's stripping endothelial keratoplasty: analysis of consecutive 430 cases

Abstract

Purpose: To analyze the complications and their managements in Descemet's stripping endothelial keratoplasty (DSEK) in consecutive 430 cases by single surgeon in a tertiary eye hospital.

Materials and methods: 430 eyes of 366 patients with endothelial dysfunctions scheduled for DSEK, were analyzed retrospectively. In all cases donor dissection was performed manually, and 'Taco' insertion and unfolding technique was used. Intra-operative and postoperative complications with their managements and outcomes were reviewed retrospectively. Periodic endothelial cell density was analyzed for each patient till the last visit. Follow-up period was between 3 to 60 months (mean 18.7 months).

Results: 13 (3.0%) eyes had operative complications during donor dissection and 16 (3.7%) had during recipient procedure. In 7 (1.6%) eyes, donor lenticule was replaced with a new one during the surgery. In early postoperative period, 21 (4.9%) eyes had donor dislocation and 12 (2.8%) eyes had air-induced pupillary block; and they were managed immediately. 2 cases had primary graft failure and in 1 case had postoperative bacterial endophthalmitis requiring evisceration. In late postoperative period, 48 (11.3%) eyes had secondary glaucoma and 14 (3.3%) eyes had late secondary graft failure. Endothelial rejection occurred in 5 (1.2%) cases. Mean endothelial cell loss was 19.7% after 3 months and 54.2% after 5 years. Total graft failure in this series was 31 (7.2%) and in 17 cases re-DSEK was performed successfully.

Conclusions: Both operative and postoperative complications do occur in DSEK. Most of these complications can be managed by medical or appropriate surgical means. Some of the complications can be avoided and reduced with experience.

Figure 1

(a) Air-induced pupillary block; (b) air-induced pupillary block in slit section

Figure 2

(a) Primary graft failure; (b) primary graft failure in slit section

Figure 3

(a) Interface infection – 7^th day postoperative; (b) interface infection – in slit section

Figure 4

(a) Donor dislocation on 2^nd day; (b) donor dislocation on 2^nd day in slit section; (c) donor dislocation on 2^nd day – anterior segment OCT picture; (d) donor reattachment after repositioning and rebubbling

Figure 5

(a) Toxic anterior segment syndrome at 7^th day; (b) toxic anterior segment syndrome – note the anterior uveitis

Figure 6

(a) Clear graft in DSEK after 3 years – secondary glaucoma; (b) glaucomatous optic atrophy – total cupping; (c) normal optic nerve of the other eye

Figure 7

(a) 360° peripheral anterior synechia; (b) 360° peripheral anterior synechia – iris bombe

Figure 8

(a) Endothelial graft rejection in DSEK; (b) endothelial graft rejection in DSEK – note corneal edema with Descemet's folds; (c) same eye after two doses of intravenous methyl prednisolone

Figure 9

(a) Late interface opacification in the pupillary area; (b) late interface opacification in slit section

Figure 10

(a) Clear graft 2.5 years after DSEK; (b) late graft failure – same eye after 3.5 years; (c) Late graft failure in slit section – same eye after 3.5 years; (d) re-DSEK-same eye – postoperative 3 months

Figure 11

Late infective keratitis with interface hypopyon

Figure 12

Percentage of periodic endothelial cell loss over last 5 years