AN UNUSUAL OCCURRENCE OF EPITHELIAL INGROWTH IMITATING INFECTION FOLLOWING DMEK SURGERY

To report our experience of epithelial ingrowth in the interface post-Descemet membrane endothelial keratoplasty (DMEK) surgery.  

Patient was examined, diagnosed and treated by the corneal team in the Ophthalmology Department at University Hospitals of Leicester NHS Trust, a tertiary care hospital.

An 81 year old female with Fuchs’ endothelial dystrophy, moderate nuclear sclerotic cataract and mild dry age-related degeneration underwent uncomplicated left DMEK combined with phacoemulsification and intra-ocular lens implant under local anaesthesia. Pre-operative best corrected visual acuity was 0.42 and 0.5 LogMAR in her right and left eye respectively.

Two hours post-surgery air was released from the anterior chamber to reduce intra-ocular pressure from 58 mmHg to 14 mmHg. A 75% air fill was maintained in the anterior chamber.

She was started on guttae Dexamethasone 0.1% two-hourly, guttae Levofloxacin 0.5% two-hourly and guttae Cylopentolate 1% three times of day. On 1 week post-operative review the graft was attached and this was confirmed with anterior segment OCT. There was some corneal oedema in the first month which gradually resolved.

At 7 weeks post-operatively her left visual acuity improved to 0.52 and 0.50 LogMAR, respectively, unaided and with pinhole. However, multiple left inferior corneal graft interface opacities were noted and suspected to be an infectious keratitis.

An emergency left anterior chamber tap was performed for routine cultures and PCR and intra-cameral Voriconazole 0.1 mL (50 mcg/0.1 mL) and Cefuroxime 0.1 mL (1mg/0.1mL) were injected under topical anaesthesia. The patient was started on guttae Levofloxacin 0.5% hourly and guttae Voriconazole 1% hourly. Guttae Dexamethasone 0.1% were temporarily stopped.

Anterior segment optical coherence tomography (OCT) confirmed inferior hyperreflective interface depositions. Bacterial and fungal culture and polymerase chain reaction results from the aqueous tap were negative. Topical antifungal and antibiotic treatment were tapered and discontinued, and topical steroids were recommenced. The opacities appeared to be unchanged clinically and on anterior segment OCT imaging. Confirmation of diagnosis of epithelial ingrowth was later obtained with confocal microscopy.

At 8 months post-operatively, her left visual acuity has remained good at 0.36 and 0.20 LogMAR unaided and with pinhole, respectively.

Epithelial ingrowth can occur after DMEK surgery as it is well described after Descemet stripping automated endothelial keratoplasty surgery. It has a clinical appearance which can mimic insidious infection and with suspicious graft interface opacites appropriate investigation and treatment are required.