Long-lasting corneal endothelial graft rejection successfully reversed after dexamethasone intravitreal implant

Abstract

Graft rejection is the most significant complication corneal transplantation and the leading indication for overall corneal transplantation. Corticosteroid therapy represents the mainstay of graft rejection treatment; however, the optimal route of administration of corticosteroid remains uncertain. We report herein for the first time the multimodal imaging of a case of long-lasting corneal endothelial graft rejection successfully reversed 3 months after dexamethasone intravitreal implant. A 29-year-old Asian female presented with a long-lasting corneal endothelial graft rejection in her left phakic eye. She underwent penetrating keratoplasty for advanced keratoconus 24 months before presentation. Hourly dexamethasone eyedrops, daily intravenous methylprednisolone, and one parabulbar injection of methylprednisolone acetate were administered during the 5 days of hospitalization. However, the clinical picture remained approximately unchanged despite therapy. By mutual agreement, we opted for the off-label injection of dexamethasone 0.7 mg intravitreal implant in order to provide therapeutic concentrations of steroid for a period of ~6 months. No other concomitant therapies were prescribed to the patient. Visual acuity measurement, slit lamp biomicroscopy, anterior segment photography, confocal microscopy, anterior segment optical coherence tomography, laser cell flare meter, intraocular pressure measurement, and ophthalmoscopy were performed monthly for the first postoperative 6 months. Three months after injection, both clinical and subclinical signs of rejection disappeared with a full recovery of visual acuity to 20/30 as before the episode. Currently, at the 12-month follow-up visit, the clinical picture remains stable without any sign of rejection, recurrence, or graft failure. Dexamethasone intravitreal implant seems to be a new potential effective treatment for corneal graft rejection, particularly in case of poor compliance or lack of response to conventional treatment. In addition, it could be especially useful in diabetic patients unable to receive systemic steroids.

Keywords: confocal microscopy; corneal graft rejection; dexamethasone intravitreal implant; keratoconus; keratoplasty.

Figure 1

Clinical picture of corneal endothelial graft rejection at baseline. Note: Slit lamp biomicroscopy with anterior segment photography at a magnification of ×16 shows intense conjunctival hyperemia and severe corneal edema with diffuse Descemet’s folds.

Figure 2

Confocal microscopy image at baseline. Note: Confocal microscopy image shows increased number of dendritic cells.

Figure 3

Clinical picture of corneal endothelial graft rejection 1 month after the injection. Note: Slit lamp biomicroscopy with anterior segment photography at a magnification of ×16 shows conjunctival hyperemia recovery and improvement in corneal transparency.

Figure 4

Clinical picture of corneal endothelial graft rejection 3 months after the injection. Note: Slit lamp biomicroscopy with anterior segment photography at a magnification of ×16 shows full recovery of corneal transparency with few residual Descemet’s folds not involving visual axis.

Figure 5

Confocal microscopy image 3 months after the injection. Note: Confocal microscopy image shows dendritic cell number within the physiological range.