ENDOTHELIAL KERATOPLASTY IN PATIENTS WITH IRIDOCORNEAL ENDOTHELIAL SYNDROME – COMPARISON OF DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY (DMEK) AND DESCEMET STRIPPING ENDOTHELIAL KERATOPLASTY (DSAEK), A CASE SERIES

To compare the outcome of Descemet membrane endothelial keratoplasty (DMEK) versus Descemet stripping endothelial keratoplasty (DSAEK) in a series of 4 patients with Iridocorneal Endothelial (ICE) syndrome.

Eye Hospital, University Medical Centre Ljubljana, Slovenia

A retrospective cases series of 4 patients diagnosed with ICE syndrome and subsequent corneal decompensation; 2 were treated with DSAEK, 1 with triple DSAEK and 1 with triple DMEK. Preoperative eye bank graft endothelial cell density (ECD; cells/mm²) value as well as best-corrected visual acuity (BCVA; Snellen), ECD (cells/mm²) and central corneal thickness (CCT; μm) before surgery and at the last follow-up (24 months mean, interval 7-30 months) are presented and compared among the different types of endothelial keratoplasty (EK). Early and late surgical postoperative complications were also recorded.

A 60-year-old man with anterior synechiae and corneal edema in the right eye (RE) successfully underwent DSAEK. Preoperative eye bank graft ECD value was 2415 cells/mm². After 30 months BCVA improved from 0.05 to 0.9; ECD was 556 cells/mm² and CCT was 657 μm. A 41-year-old woman with secondary glaucoma with implanted Baerveldt implant after a failed trabeculectomy and corneal decompensation in the RE was treated with DSAEK. Preoperative eye bank graft ECD value was 2950 cells/mm². Graft rejection and a herpetic infection were treated due to large precipitates 9 months after the transplantation. Persistence and pigmentation of the precipitates indicated ICE cells spreading to the endothelium. However, after 18 months the result was still very good as BCVA improved from counting fingers (CF) at 1 meter to 0.6; ECD was 1220 cells/mm² and CCT was 622 μm. A 66-year-old man with bullous keratopathy, cataract and secondary glaucoma after trabeculectomy in the left eye (LE) successfully underwent triple DSAEK. Preoperative eye bank graft ECD value was 2801 cells/mm². The procedure was complicated with late anterior synechiae formation which was resolved using synechiolysis. Seven months after the EK, a revision of the filtering bleb was necessary as well. After 7 months BCVA improved from CF at 1 meter to 0.2 and ECD was 1920 cells/mm². A 75-year-old woman with bullous keratopathy and secondary glaucoma on topical therapy in the LE successfully underwent triple DMEK. Preoperative eye bank graft ECD value was 2924 cells/mm². After 34 months BCVA improved from 0.25 to 1.0; ECD was 1598 cells/mm² and CCT was 455 μm.

Management of corneal decompensation in ICE syndrome with EK is challenging due to pathologically changed anterior chamber structures and often prior glaucoma surgical intervention. Furthermore, the prognosis of the endothelial graft can be worsened by spread of the ICE cells. The presented series demonstrated that DSAEK was a good choice in patients with previous glaucoma surgery, while DMEK had a better BCVA and ECD outcome and might be a better choice if technically possible.