• Users Online: 34
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 89-91

The aftermath of retained Descemet's membrane: A case report and review of literature


1 Cornea, Ocular Surface, Trauma and Refractive Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, TamilNadu, India
2 Paediatric and Strabismology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, TamilNadu, India
3 Glaucoma Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, TamilNadu, India

Date of Submission07-Nov-2021
Date of Decision30-Dec-2021
Date of Acceptance05-Jan-2022
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Venugopal Anitha
Cornea, Ocular Surface, Trauma and Refractive Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_166_21

Rights and Permissions
  Abstract 


This study aimed to report the graft sequelae of retained host Descemet's membrane (DM) following Penetrating Keratoplasty (PKP). A 75-year-old male diagnosed with retained host DM with Anterior segment optical coherence tomography (ASOCT). Nd:YAG membranotomy resulted in graft failure. Later, DM stripping endothelial keratoplasty with removal of the host DM was done. Review of literature was done to discuss the best treatment modality.

Keywords: Descemet's membrane stripping endothelial keratoplasty, Nd:YAG laser membranotomy, retained Descemet's membrane


How to cite this article:
Anitha V, Ravindran M, Rangappa R. The aftermath of retained Descemet's membrane: A case report and review of literature. TNOA J Ophthalmic Sci Res 2022;60:89-91

How to cite this URL:
Anitha V, Ravindran M, Rangappa R. The aftermath of retained Descemet's membrane: A case report and review of literature. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Jul 2];60:89-91. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/89/340359




  Introduction Top


Fuchs endothelial corneal dystrophy (FECD) is characterized by dysfunctional endothelium. The conventional treatment is the replacement of full thickness (PKP) or the part of the diseased cornea (endothelial keratoplasty) with healthy tissue. FECD is responsible for 41.89% of the corneal dystrophies in India[1] and 16.6% in South India.[2] The disease progression results in prolonged corneal stromal edema and spontaneous loosening of the Descemet's membrane (DM) layer, leading to inadvertently retained host DM following PKP. A 75-year-old male with FECD was diagnosed with primary graft failure in the immediate postoperative period following PKP. Later, after 2 weeks, a retrocorneal membrane was noted and identified as inadvertent retention of the host DM with anterior segment optical coherence tomography (Visante ASOCT, Carl Zeiss, and Germany).


  Case Report Top


A 75-year-old male, a known case of FECD, presented with defective vision in both eyes (BE). The best-corrected visual acuity in the right eye was 20/200, and counting fingers (CF) in the left eye was 3′. In the right eye, PKP was done twice, 3 years back. The right eye revealed vascularized partially opaque, failed graft, normal anterior chamber (AC) depth, and pseudophakia on slit-lamp examination. The left eye showed diffuse, edematous cornea with guttae on the endothelium and pseudophakia. Ultrasonography B scan was within normal limits in BE. The Intraocular pressure was 16 mmHg in BE. PKP in the left eye was planned. An 8 mm donor cornea with 2500 endothelial count/mm2 and 7.5 mm trephine was used to cut through the recipient cornea in a controlled rotatory manner until the AC was entered. The scissors were used to separate and remove the recipient button. The peripheral iridectomy was done with Vannas scissors at 12 o'clock. During the 1st postoperative day, the left eye graft appeared edematous with no view of AC. Hence, the diagnosis of primary graft failure was made. Topical gatifloxacin (0.3%)–dexamethasone (0.1%) eye drops were started hourly and tapered slowly along with low-dose systemic steroids. After 2 weeks of the 1st postoperative follow-up, the graft appeared clear, with a membrane seen in the aqueous humor [Figure 1]a with vision 20/80. It was identified as a retained host membrane with the ASOCT [Figure 1]b. It was seen as a thin 360° circular membrane found attached to the graft–host junction posteriorly. The patient was followed with serial ASOCT; with time, the host DM appeared to move nearer to the posterior surface of the graft with increasing opacification. The vision dropped from 20/80 to 20/100 at 6-month follow-up. With the aim of conservative management, Q switched Nd:YAG laser to create a central 3 mm opening in opacified retained DM, with 2.6 joules energy and 53 shots. Surprisingly, after the YAG laser, the patient presented with a decrease in vision to CF at 3′; turbid white fluid was noted between the graft and the retained DM. Topical steroid eye drops were stepped up and tapered after complete resolution of the fluid.
Figure 1: (a) Image shows penetrating keratoplasty graft with retained opacified Descemet's membrane (b) Serial ASOCT showing retained Descemet's membrane (c) Post Descemet's membrane stripping endothelial keratoplasty and removal of host Descemet's membrane with clear graft

Click here to view


Consequently, graft failed with opacified host DM in the AC. After 4 months, trypan blue dye assisted surgical removal of retained old DM was done along with the manual stripping of the PKP graft- endothelium DM complex and replaced with 8mm new donor DSEK graft with endothelial count of 2900 cells/mm2. The graft was prepared with an artificial AC and inserted into the AC by taco technique [Figure 1]c. An air bubble was injected to position the graft. Postoperatively, combination of gatifloxacin (0.3%) and dexamethasone (0.1%) eye drops was prescribed in tapering doses for 6 months, and homatropine eye drops bidaily for 1 week. The graft is clear with 20/40 vision at a 1-year follow-up.


  Discussion Top


Inadvertent retention of host DM is a rare complication following PKP.[3] The predisposing factors include prolonged stromal edema, which may lead to spontaneous detachment of DM in FECD with abnormally thickened DM[1],[2],[3] which may be overlooked during the surgery. The surgeon's factor, such as incomplete trephination followed by accidental viscoelastic injection in between the host stroma and the DM, may lead to the separation of DM intraoperatively, leading to retention postoperatively.[3],[4] Our patient is a known case of FECD with corneal decompensation for which PKP was planned due to diffuse stromal scarring. Initially, he was diagnosed with primary graft failure due to persistent graft edema, but only after 2 weeks, the retrocorneal membrane was noted, and ASOCT images confirmed retained DM. The first report of retained DM was described by Lifshitz et al. in two patients after PKP in 200.[5] Barrio et al. reported a similar case of retained DM in an 88-year-old male following PKP, unnoticed until the visual acuity decreased.[6] Later, Nd: YAG improved the visual acuity. Thyagarajan et al.[7] reported retention of DM in PKP for decompensated cornea secondary to silicone oil. Masket and Tennen[8] noted retained DM in 78-year-old women after PKP in a patient with PBK due to Anterior chamber intraocular lens (ACIOL). The retrocorneal membrane was diagnosed 6 months after surgery, and Nd:YAG improved the visual acuity. In contrast, the Nd:YAG laser in our patient resulted in graft failure. Like our case, Kremer et al. had noted five patients (0.37%) with inadvertent retained DM, Nd:YAG was done at 2 weeks to the retained membrane and consequently noted graft failure within 6–8 weeks, necessitating repeat PKP with the removal of DM.[9] The graft failure was due to direct shock wave damage to the endothelium by the Nd:YAG laser (probably due to less distance between the endothelium and laser focus <1 mm).[3],[5] Kim et al. also reported the loss of endothelial count 1 month after YAG laser.[10] The whitish fluid noted between retained DM and the graft in our patient was probably inflammatory. The most common indication for YAG laser or the surgical removal of the retained DM is its progressive opacification.[1] A minimal amount of stroma adherent to the DM activates the fibroblastic activity of keratocyte, leading to opacification.[1] In our case, opacification of retained DM occurred after 6 months of surgery; since YAG failed, surgical removal was opted. Many authors have preferred surgical removal of retained DM with various modified techniques such as triamcinolone acetonide-assisted descemetectomy, the use of femtosecond laser, and trypan blue-assisted descemetorhexis,[1],[4],[11] before the graft failure sets into circumvent the second graft. Intraoperatively, after trephination of the host cornea, meticulous examination of the AC for membrane would avoid such rare complications. Our case highlights retained DM as an important differential diagnosis in poor visual recovery during the early postoperative period, Nd:YAG laser membranotomy as a trigger factor for inflammation and endothelial failure and surgical removal would be the best option for long-term good visual outcome.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Das AV, Chaurasia S. Clinical profile and demographic distribution of corneal dystrophies in India: A study of 4198 patients. Cornea 2021;40:548-53.  Back to cited text no. 1
    
2.
Pandrowala H, Bansal A, Vemuganti GK, Rao GN. Frequency, distribution, and outcome of keratoplasty for corneal dystrophies at a tertiary eye care center in South India. Cornea 2004;23:541-6.  Back to cited text no. 2
    
3.
McVeigh K, Cornish KS, Reddy AR, Vakros G. Retained Descemet's membrane following penetrating keratoplasty for Fuchs' endothelial dystrophy: A case report of a post-operative complication. Clin Ophthalmol 2013;7:1511-4.  Back to cited text no. 3
    
4.
Chen YP, Lai PC, Chen PY, Lin KK, Hsiao CH. Retained Descemet's membrane after penetrating keratoplasty. J Cataract Refract Surg 2003;29:1842-4.  Back to cited text no. 4
    
5.
Lifshitz T, Oshry T, Rosenthal G. Retrocorneal membrane after penetrating keratoplasty. Ophthalmic Surg Lasers 2001;32:159-61.  Back to cited text no. 5
    
6.
Tabuenca-Del Barrio L, Iturralde-Errea O, Mozo-Cuadrado M, Zubicoa-Enériz A, Plaza-Ramos P. Persistence of Descemet membrane and recipient-type endothelium after keratoplasty. A case report. Arch Soc Esp Oftalmol (Engl Ed) 2019;94:343-6.  Back to cited text no. 6
    
7.
Thyagarajan S, Mearza AA, Falcon MG. Inadvertent retention of Descemet membrane in penetrating keratoplasty. Cornea 2006;25:748-9.  Back to cited text no. 7
    
8.
Masket S, Tennen DG. Neodymium: YAG laser optical opening for retained Descemet's membrane after penetrating keratoplasty. J Cataract Refract Surg 1996;22:139-41.  Back to cited text no. 8
    
9.
Kremer I, Dreznik A, Tessler G, Bahar I. Corneal graft failure following Nd:YAG laser membranotomy for inadvertent retained Descemet's membrane after penetrating keratoplasty. Ophthalmic Surg Lasers Imaging 2012;43:e94-8.  Back to cited text no. 9
    
10.
Kim YC, Hwang JH, Kim MS. Clinical outcomes of Nd-YAG laser membranotomy in retained host corneal membrane after keratoplasty. J Korean Ophthalmol Soc 2015;56:664.  Back to cited text no. 10
    
11.
Tyring A, Chang O, Jung H. Triamcinolone acetonide-assisted descemetectomy for retained Descemet membrane. Case Rep Ophthalmol 2018;9:227-31.  Back to cited text no. 11
    


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed252    
    Printed18    
    Emailed0    
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]