Treatment Of Late Descemetic Detachment After Penetrating Keratoplasty By Modified Deep Anterior Lamellar Keratoplasty

To report the outcomes of modified deep anterior lamellar keratoplasty (DALK) for the treatment of late Descemet membrane detachment occurring 15 years after penetrating keratoplasty (PK) for keratoconus.

Tertiary Eye Care Referral Center (Ospedali Privati Forlì “Villa Igea”, Forlì, Italy).

A 41-year-old female presented to our clinic with a 3-month history of painless blurred vision in the left eye. Corneal stroma edema was observed inferiorly extending beyond the graft margin. The superonasal cornea was clear with normal thickness. AS-OCT showed central detachment of Descemet’s membrane (DM) extending inferiorly with a corresponding corneal thickness inferiorly of 964 microns. The cornea remained clear in areas with attached DM. After failed attempts of graft attachment via intracameral injection of air, a modified DALK was performed. Trephination of the recipient bed, about 250μm in depth and 9mm in diameter was performed, followed by centripetal lamellar dissection across the PK wound.  The stromal component of the old PK wound was opened using blunt-tipped Vannas scissors until the plane of DM detachment was found. The stroma was peeled from the underlying recipient bed. A donor anterior corneal lamella cut by means of a 450μm microkeratome head, punched to 9mm was sutured in place. One year postoperatively, the patient achieved BSCVA of 6/6 with a clear cornea, attached DM and endothelial cell density of 1228 cells/mm2.

Exchanging only the anterior lamella in a case of late DM detachment in a post-PK cornea with previous ectasia is technically feasible and compatible with excellent visual acuity. This supports the hypothesis that in such cases the primary pathological process leading to DM detachment originates from the anterior and not the posterior lamella.