Incidental central tear in Descemet membrane endothelial complex during Descemet membrane endothelial keratoplasty

Abstract

Descemet membrane endothelial keratoplasty (DMEK) was performed in a 70-year-old man diagnosed with pseudophakic bullous keratopathy. During Descemet endothelial complex (DEC) preparation, a central tear was noticed in the DMEK graft. However, the surgery was continued. On sixth postoperative day, a small fluid pocket was observed between the DEC and the posterior host stroma in inferior third of the graft area. It was, however, decided to observe it for spontaneous attachment. At 2 weeks, the inferior DEC detachment had increased with overlying corneal oedema. Descemetopexy with 100% air was performed the same day which reattached the DEC. Subsequently, DEC remained attached and at the last follow-up of 2 months, DEC was well opposed with a clear overlying cornea. The final best-corrected Snellen's visual acuity was 20/60. A small tear in the DEC does not necessitate tissue replacement and a good anatomical and visual outcome can be achieved in such cases.

Figure 1

Composite of slit lamp images showing diffuse and slit images of the patient. (A) Diffuse illumination image showing central and inferior cornea oedema at presentation; (B) postoperative day 1 photograph after Descemet membrane endothelial keratoplasty (DMEK) showing reduction in corneal oedema and an anterior chamber filled half with air bubble; (C) diffuse and (D) slit views at postoperative 3 weeks showing inferior corneal oedema with Descemet endothelial complex (DEC) separation; and (E) diffuse and (F) slit views at postoperative 2 months after air descemetopexy was performed showing an attached DMEK DEC with an overlying clear cornea.

Figure 2

(A) Intraoperative photograph showing a central tear in the Descemet endothelial complex (DEC) during donor preparation. (B and C) the customised DEC injector.

Figure 3

Anterior segment optical coherence tomography pictures of the inferior cornea on (A) postoperative day 1 showing an attached Descemet membrane endothelial keratoplasty (DMEK) graft; (B) on postoperative day 6 when a thin Descemet membrane separation was seen; (C) at postoperative week 3 when the DMEK separation had increased with overlying corneal oedema; and (D) 1 month after successful repeat air injection was performed showing an attached DMEK graft with a clear overlying cornea.

Figure 4

Macular Optical Coherance Tomograohy scan showing cystoids macular edema, cause for a decreased visual acuity despite clear cornea.

Figure 5

Specular photo-micrograph showing the endothelial cell count of 1580 cells/mm² at 2 months follow-up.