Persistent Localised Descemet Membrane Endothelial Keratoplasty Detachments Secondary To Corneal Ink Stain Mark

Endothelial graft detachment is the most common complication post DMEK surgery with a wide range of causes including: patient factors, surgical technique, donor tissue quality and ophthalmic co-morbidities. Correct orientation of the donor lenticule within the anterior chamber is essential for DMEK success.

We describe two consecutive cases  of  persistent post-operative localised graft detachments directly under the gentian violet ink mark.

Cornea department in UK Tertiary Referral Centre

Two patients underwent consecutive uncomplicated DMEK surgery for Fuchs endothelial dystrophy with identical donor peeling under SCUBA technique followed by standard DMEK procedure with air bubble tamponade. Gentian violet ink (Easi-mark Surgical Skin Marker, Fannin, UK) was directly transferred onto the end of a Sinsky hook and then singly applied to via a dried scleral window to achieve an ‘F.’ configuration. This was a first instance of using this marking pen due to supply shortage of usual pen used.  

Both patients had localised detachments around the F mark on day 1, week 1 and up to 1 month at post-operative review.

Patient one presented day 3 post-op with a 50% superior graft detachment overlying the F mark, whilst the remainder of the donor tissue was attached. A re-bubble at the slit lamp was necessary. At week 1, the F mark was still present with localised oedema and at week 3 there was localised detachment around the mark but otherwise a clear cornea. The F mark persisted at 6 weeks with overlying corneal haze but no detachment confirmed on AS-OCT. BCVA improved from HM to 6/9.

Patient two presented day 1 post-op with shallow inferonasal detachment. A small detachment overlying the F mark persisted with a corresponding area of microcystic oedema until week 6 when graft was attached but F mark still present. BCVA improved from CF to 6/15.

This paper illustrates clinical evidence of endothelial toxicity which directly corresponds with the area of ink mark and chronic graft detachment. We hypothesise the difference in solvent used in this marker pen (50% isopropyl alcohol) as opposed to the aqueous base of the pen usually used may have contributed to the chronic detachment seen. Studies observing vein graft marking with similar marker pens have shown similar cell dysfunction due to solvents used in these pens. Whilst ink staining is a useful adjunct in correct donor graft orientation, caution is advised in the type of solvent present in the marking pen and its concentration.