Bilateral Sequential Descemet's Membrane Detachments 35 Years After Penetrating Keratoplasties

Descemet’s membrane detachment (DMD) is generally seen as an iatrogenic complication of cataract or glaucoma surgery or the result of blunt trauma. More rarely, Descemet’s membrane detachment may develop spontaneously in cases of corneal ectasia or as a delayed presentation post-surgery in predisposed cases. The aim of this report was to present and discuss the management of a bilateral sequential Descemet’s membrane detachment in a keratoconic patient, thirty-five years after bilateral penetrating keratoplasty.

Ophthalmology Department, King’s College Hospital NHS Foundation Trust

A 52-year-old Caucasian keratoconic male, 35 years post penetrating keratoplasty (PKP), presented with painless, sudden loss of vision in the right eye (counting fingers vision) and diffuse corneal edema. His previous ophthalmic history included bilateral PKP in 1991-1992, bilateral cataract surgery in 2000, bilateral astigmatic keratotomies in 2006 and a right toric secondary lens in 2010, YAG capsulotomy and a diagnosis of primary open angle glaucoma in 2010.

2 weeks after a diagnosis of acute corneal graft rejection and treatment with intensive topical and systemic steroids, the patient attended the corneal clinic. OCT imaging showed a central linear Descemet’s membrane detachment (DMD) extending into the pupil area for more than 2mm length and more than 300 microns height. A Descemetopexy with sterile air injection was performed twice with recalcitrant DMD within 48 hours. A successful Descemet’s stripping endothelial keratoplasty (DSAEK) was performed with excellent visual recovery in the right eye. 5 years later the patient presented with a week’s history of sudden, painless blurred left vision (6/60 Snellen) and a partial corneal edema. The OCT scan showed a paracentral wavy DMD with bullous pattern, without a scroll, extending more than 1mm in length and 100 microns in height. A Descemetopexy with sterile air injection failed to resolve the DMD and the patient underwent a left DSAEK with excellent visual recovery. The final visual acuity was 6/9 unaided in both eyes.

Spontaneous DMD is a rare cause of acute corneal oedema and sudden loss of vision in cases of corneal ectasia or delayed complication post-surgery. The presence of corneal edema and a previous history of keratoplasty misled the diagnosis towards the possibility of corneal graft rejection. Descemetopexy with intracameral injection of air/gas is the primary treatment options for DMD, however, Endothelial Keratoplasty may be necessary for the management of persistent or recalcitrant cases. This case describes a rare presentation of bilateral spontaneous DMD and highlights the importance of anterior segment OCT imaging in determining the aetiology of corneal edema and planning the surgical intervention.