A Surpise Guest After Complex Dmek Surgery

Epithelial ingrowth has been described in three cases of DMEK in the literature. This complication can result in a decrease in visual acuity or even graft failure. In the most severe cases, a new endothelial or penetrating graft is indicated.

A 76-year-old patient underwent a new DMEK surgery after failure of a previous graft, for bullous keratopathy. Slit-lamp examination revealed severe stromal and epithelial edema, and stromal fibrosis. Vitreous was present in the anterior chamber, and the intraocular lens was unstable in the capsular bag.  

Epithelium was debrided at the beginning of the intervention. Anterior vitrectomy was performed and the failed graft removed. No rebubbling was necessary in the postoperative period. Edema regressed at 1 month postoperatively. At 3 months, a round lesion with clear walls and halo-llike feature appeared in the interface between the stroma and the graft in the superior nasal quadrant. Corneal OCT revealed a hyper-reflective content cyst, continuous with the main incision. Epithelial invasion cyst was suspected. There was no graft detachment. Central pachymetry increased by 70 microns. Simple observation was recommended. At 4 months, the cyst was stable. 

The main risk factor for epithelial ingrowth in this case was epithelial debridement at the beginning of the intervention. The recipient's epithelial cells may have migrated through the main incision, as suggested by the localization of the cyst and the presence of a hyper-reflective continuity line between the main incision and the cyst on OCT. Encapsulation of epithelial cells could explain the stability of the cyst. Given the stability of the cyst and the absence of graft detachment, simple monitoring was recommended in this case.