Intrastromal Anti-Vegf With Endothelial Keratoplasty: A Case Series On Corneal Clarity And Neovascular Regression

This case series evaluates the effectiveness of intrastromal anti-vascular endothelial growth factor (anti-VEGF) injections as an adjunct to endothelial keratoplasty in patients with corneal decompensation and significant corneal neovascularization. Corneal neovascularization poses a major challenge in keratoplasty, increasing the risk of graft failure and rejection. This study aims to assess whether targeted intrastromal anti-VEGF administration following Descemet’s Stripping Endothelial Keratoplasty (DSEK) and Descemet Membrane Endothelial Keratoplasty (DMEK) can promote regression of corneal vessels, improve graft survival, and enhance corneal clarity in high-risk patients.

A case series conducted at a tertiary eye care hospital in India, evaluating two patients with pseudophakic corneal decompensation and significant corneal vascularization who underwent endothelial keratoplasty with adjunctive intrastromal anti-VEGF therapy. The procedures, performed by an experienced corneal surgeon, aimed to assess the efficacy of intrastromal anti-VEGF in promoting vascular regression and improving corneal clarity in high-risk graft recipients.

2 patients with corneal decompensation&neovascularization underwent endothelial keratoplasty with intrastromal anti-VEGF.1st patient-pseudophakic bullous keratopathy (PBK) with a scarred Descemet’s membrane (DM),significant scarring,edema,vascularization had DSEK+intrastromal anti-VEGF injection.2nd patient also with PBK,less extensive vascularization, underwent DMEK+intrastromal anti-VEGF.Both patients received a standardized dose of anti-VEGF into the stromal plane near the areas of active vascularization.The primary outcome measures were reduction in vascularization,improvement in corneal clarity&best-corrected visual acuity (BCVA) at 1&3Mo Postop.Secondary outcomes assessed graft adherence,complications,need for additional interventions

One month postoperatively, both cases showed significant regression of corneal neovascularization and improved clarity. The first patient (DSEK + anti-VEGF) had marked vessel regression, reduced scarring, and stable graft adherence without signs of rejection. The second patient (DMEK + anti-VEGF) also showed substantial vascular regression, excellent graft adherence, and improved corneal transparency. Best-corrected visual acuity improved in both cases, 1st case improved from HM to 6/18, 2nd case 20/200 to 20/60. No complications, inflammation, or endothelial rejection were observed. At three months, the vascular regression was sustained, with no recurrence of neovascularization. Graft was central, well adhered and clear in both the cases.

Intrastromal anti-VEGF with endothelial keratoplasty effectively reduces corneal neovascularization and enhances graft survival in high-risk patients. By targeting stromal vascularization, this approach improves corneal clarity and may lower the risk of graft rejection. Both cases showed stable graft adherence and sustained vascular regression without complications, indicating potential safety and efficacy. This adjunctive therapy could benefit patients with extensive corneal vascularization. Further studies with larger cohorts are needed to validate long-term benefits and optimize treatment protocols.