Penetrating Keratoplasty As A Solution To Multiple Failed Endothelial Keratoplasties

Based on a real case, we aim to evaluate the management of endothelial keratoplasty rejection, specifically, Descemet’s membrane endothelial keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK), and report the effectiveness of penetrating keratoplasty (PK) as a solution to multiple graft failures.

Department of Ophthalmology, Mútua Terrassa University Hospital, Terrassa, Barcelona, Spain.

We report the case of a 66-year-old male patient with Fuchs’ dystrophy who presented corneal decompensation after cataract surgery in both eyes (OU). His history of interest included high blood pressure, diabetes, and dyslipidemia. A DMEK and a DSAEK were performed in his right (RE) and left eye (LE), respectively. Another DMEK was necessary two years later in his RE and seven years later in his LE. The patient remained stable, occasionally showing signs of graft rejection that were controlled with topical and oral corticosteroids. Four years later from his last surgery, the patient began experiencing bilateral graft rejection without response to medical or surgical treatment.

Graft rejection was treated with a combination of corticosteroids and topical immunosuppressants, along with oral tacrolimus. Over time, the patient developed fluctuating ocular hypertension that worsened corneal decompensation. Given its poor control with topical and oral treatment, filtration surgery was performed in OU. Blood tests, immunological studies and PET-CT showed normal results. Although aqueous humor PCR results were negative, we initiated empirically valacyclovir and later valganciclovir without good response. Another re-DMEK was performed in the RE and an UT-DSAEK in the LE, with graft rejection shortly after. Systemic immunosuppression was changed to mycophenolate mofetil. The case finally stabilized through PK in OU.

PK is an effective and feasible method for managing failed DMEK or DSAEK grafts. While the literature shows that typically PK has higher graft rejection rates than endothelial keratoplasties, especially in first-time transplant, PK can offer more reliable and stable long-term outcomes, by restoring full corneal integrity. Thus, PK must particularly be considered in those cases with several endothelial keratoplasty failures. Multidisciplinary management may be necessary to rule out other underlying pathologies and adjust treatment, as graft rejection can be a real challenge.