Late Central Graft Detachment Due To Double Endothelial Layer After Repeat Descemet Membrane Endothelial Keratoplasty

To report late central graft detachment after repeat Descemet membrane endothelial keratoplasty (DMEK) without visual reduction.

Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany.

A 71-year-old patient with Fuchs’ endothelial corneal dystrophy received a DMEK in his left eye. At 11 month post-operatively, a subtotal graft detachment was noted. Due to increasing corneal edema with vision loss, the first DMEK was removed and a repeat-DMEK was performed. At four months post repeat-DMEK, the graft was fully adherent to the posterior stroma. There was no significant corneal edema, and the best corrected visual acuity was 20/25. At 16-months after repeat-DMEK, a central graft detachment was noted, but there was no concurrent corneal edema or any loss of visual acuity. The mean density of the central endothelial cells was measured at 842 cells/mm². Given the lack of corneal edema, visual reduction or subjective visual complaint, the graft detachment was followed-up for up to 20-months post repeat-DMEK with no further intervention, where the central cornea remained clear.

To our knowledge, this is the first report of a central repeat-DMEK graft detachment that occurred 16 months after surgery despite initial attachment. Interestingly, there was no concurrent corneal edema or vision reduction. Endothelial cells may have migrated from the subtotal detached first DMEK onto the corneal stroma resulting in central graft detachment. This highlights the importance of stromal polishing when performing a repeat endothelial keratoplasty to remove all residual migrated endothelial cells.