Prevention and management of graft detachment in DMEK
Published on: Mar 4, 2016
Transcripts - Prevention and management of graft detachment in DMEK
Prevention and management of graft detachment in DMEK K. Moutsouris, M. Dirisamer, I . Dapena, K. van Dijk, G.R.J. Melles Netherlands Institute for Innovative Ocular Surgery Melles Cornea Clinic Amnitrans Eyebank RotterdamPurpose: To describe the prevention and management of various types of graft detachment after Descemet membrane endothelial Results: Partial or complete graft detachment was found in 36 cases (24%), of which 18 (12%) were clinically significant (TAB. 1). Allkeratoplasty. 24 eyes with a partial detachment (groups 1 and 2) showed spontaneous corneal clearance, and all but 6 of these eyes (75%) reached visual acuity of 20/40 or better (≥0.5). A reversed clearance pattern and interface spikes were observed in eyes with the graftMaterials and Methods: In 150 consecutive eyes that underwent Descemet membrane endothelial keratoplasty, the incidence and type of positioned upside down (group 3) (FIG. 3). Eyes with a free-floating graft (group 4) showed persistent corneal edema. Detachmentsgraft detachment were studied at 1, 3, 6, 9, 12, and 24 months after surgery in a nonrandomized, prospective clinical study at a tertiary were associated with inward folds (12 eyes [33%])(FIG. 4), insufficient air-bubble support (7 eyes [19%]), upside-down graftreferral center. Four groups of detachments were identified: a partial detachment of one-third or less of the graft surface area (n = 16; group positioning (4 eyes [11%]), use of plastic materials (2 eyes [6%]), irido-graft synechiae (1 eye [3%])(FIG. 5), poor endothelial1); a partial detachment of more than one-third of the graft surface area (n = 8; group 2); a graft positioned upside down (n = 4; group 3); morphology (1 eye [3%])(FIG. 6), and stromal irregularity under the main incision (1 eye [3%]); 14 (58%) of the partial detachmentsand a free-floating Descemet roll in the host anterior chamber (n=8; group 4). (FIG. 1 & 2) were localized inferiorly (TAB. 2). Conclusions: Awaiting spontaneous clearance may be advocated in eye with a partial detachment. Minor adjustments in surgical protocol (FIG. 7) as well as careful patient selection may further reduce the incidence of graft detachment after Descemet membrane endothelial keratoplasty to 4% or less. Series II Series I Total Type (Cases 76-150) (Cases 1-75) n=150 n=75 n=75 Partial graft detachment ≤ 1/3 6 (8%) 10 (13%) 16 (11%) Partial graft detachment > 1/3 5 (7%) 3 (4%) 8 (5%) Graft upside-down 3 (4%) 1 (1%) 4 (3%) 1 (1%) Complete graft detachment 7 (9%) 8 (5%) Figure 4. Slitlamp photographs of a transplanted cornea 7 weeks (A), 3 months Total 21 (28%) 15 (20%) 36 (24%) (B), and 10 months (C) after Descemet membrane endothelial keratoplasty. The edema (white arrows) overlying the detached Descemet graft (yellow arrows) Clinically significant 15 (20%) 3 (4%) 18 (12%) resolves with time, and stromal thinning with concomitant corneal clearance progresses from the periphery toward the corneal center (green arrows). Furthermore, note that the relatively small inward fold of the peripheral Descemet graft causes a much larger detachment because the tissue springs away from the Table 1. Incidence of Graft Detachment recipient posterior stroma. Inset of B, Inward fold at higher magnification. Figure 5. Slitlamp photograph of a transplanted cornea 2 months after Group III Descemet membrane Group I Group II Group IV endothelial Suspected cause of graft Graft upside- Total keratoplasty. Partial graft Partial graft Complete graft Gonioscopy showed detachment down detachment ≤ 1/3 detachment > 1/3 detachment an adhesion between the Descemet graft Inward fold 9 (57%) 2 (25%) -- 1 (12.5%) 12 (33%) (arrows) and the peripheral iris, Irregular incision causing a local 1 (6%) -- -- -- 1 (3%) site traction detachment because the detached Irido-Descemet 1 (6%) -- -- -- 1 (3%) part of a Descemet graft adhesion graft tends to contract Poor endothelial Figure 2. Pachymetry and Scheimpflug images of 3 cell morphology 1 (6%) -- -- -- 1 (3%) over time. corneas 6 months after Descemet membrane Figure 1. Detachment patterns observed in our study. endothelial keratoplasty. Use of plastic materials A, In the presence of a partially detached Descemet A, In groups 1 and 2, despite the presence of a contacting donor -- 1 (12.5%) -- 1 (12.5%) 2 (6%) membrane endothelial keratoplasty (DMEK) graft, the tissue Figure 3. Slitlamp photographs of a transplanted detachment of the donor Descemet graft (arrow), the cornea 1 month (A-C) and 12 months (D-F) after central cornea covered by the graft as well as the host entire cornea shows recovery of corneal clarity Inadequate air- peripheral stroma not covered by the graft frequently bubble support Descemet membrane endothelial keratoplasty. There is (asterisks) and normal pachymetry values. (vitreous pressure -- 3 (37.5%) -- 4 (50%) 7 (19%) a reversed corneal clearance pattern with persistent showed either spontaneous reattachment of the graft B, In group 3, in the presence of a graft positioned or preceeding or complete clearance within 1 to 6 months. B, If the vitreo-retinal stromal edema (blue arrows) overlying the area upside down (with the donor endothelium facing the surgery) showing graft attachment as well as corneal clearance Figure 7. Diagram displaying recommendations to prevent detachments in DMEK graft had been positioned upside down, a recipient posterior stroma), a reversed clearance Descemet membrane endothelial keratoplasty (DMEK) and a decision tree in the reversed clearance pattern was observed, ie, the area Descemet graft -- -- 4 (100%) -- 4 (11%) (green arrows) in the area where the Descemet graft event of a Descemet graft detachment. AC indicates anterior chamber; BCVA, pattern is seen, ie, a clear cornea in the area of the upside-down (yellow arrows) is clearly detached. There is fibrous best-corrected visual acuity; DSAEK, Descemet stripping automated endothelial not covered by the graft showed complete corneal detachment (white asterisks) but persistent corneal keratoplasty; DSEK, Descemet stripping endothelial keratoplasty; and PAS, clearance within 1 to 6 months, whereas the area in Unknown 4 (25%) 2 (25%) 2 (25%) 8 (22%) scarring at the donor-host interface (red arrows) that peripheral anterior synechiae. edema over the area where the donor tissue is -- may be absent in uncomplicated eyes undergoing Figure 6. Light microscopy (A), slitlamp (B and C), and specular microscopy (D) which the graft was attached showed persistent attached (red asterisks). images of a Descemet graft before (A) and after (B-D) surgery. A, Although the edema. C, No corneal clearance was seen with a free- 16 (100%) 8 (100%) 4 (100%) 8 (100%) 36 (100%) Descemet membrane endothelial keratoplasty. This endothelial cell layer appears normal during preoperative evaluation in the C, In group 4, complete graft detachment, ie, a free- reversed clearance pattern with interface fibrosis may eyebank, Fuchs dystrophy–like changes are seen across the transplant after floating Descemet roll in the anterior chamber, ie, in floating Descemet roll in the anterior chamber surgery, while the cell density is virtually normal. B, The arrows indicate the area the absence of a touch between the graft and the Table 2. Suspected Cause of Graft Detachment be typical for eyes in which the Descemet graft was in which the graft is detached; the overlying cornea cleared despite the (arrow), is associated with persistent corneal edema. positioned upside down. detachment. recipient cornea.