Descemet Membrane Endothelial Keratoplasty For Failed Deep Anterior Lamellar Keratoplasty

The most common reasons for recurrent corneal transplantation in deep anterior lamellar keratoplasty (DALK) are patient dissatisfaction with visual acuity, deep stromal and interface opacification and/or vascularisation and persistent Descemet’s membrane (DM) detachment. Penetrating keratoplasty (PK) is the most common surgery for failed DALK followed by repeat DALK. We report a case of a patient that has undergone a Descemet’s membrane endothelial keratoplasty (DMEK) for a failed DALK.

Southend University Hospital, Mid and South Essex NHS Foundation Trust.

A 71-year-old gentleman with a history of left eye herpes simplex keratitis and dense corneal stromal scarring with hand movement (HM) vision underwent DALK in April 2021. This was achieved through a ‘viscobubble’ assisted dissection after a failed pneumatic dissection. A 9 mm trephination was carried out with the removal of the deep stroma limited to the central 6 mm optical zone creating a 360° posterior stromal shoulder. The patient then underwent phacoemulsification and insertion of intraocular lens in August 2021 due to a brunescent cataract and HM vision. Subsequently, the patient developed pseudophakic bullous keratopathy with a Snellen vision 6/60. After removal of the corneal sutures, the patient underwent a DMEK (in DALK) in December 2022. A manual descemetorhexis was carried out under air and an 8.5mm DMEK donor graft was used with air tamponade. The patient required the graft to be re-bubbled 3 times over a period of 10 days. 2 months post op, the DMEK graft remains attached with the patient achieving a BSCVA of 6/12 with a refraction of -3.00/-6.00x60. The patient is awaiting manual relaxing incisions to reduce his corneal astigmatism.

There are several advantages of carrying out DMEK for a failed DALK over repeat PK. These include the avoidance of an ‘open sky’ procedure and the risk of an expulsive haemorrhage, faster visual recovery, and a lower rejection rate.