Corneal Necrosis After Artificial Endothelial Layer (Endoart) For Penetrating Keratoplasty Decompensation

To describe a case of stromal necrosis in a penetrating keratoplasty (PK) after artificial endothelial implant EndoArt implantation to treat bullous keratopathy. 

Anterior segment department in Rothschild Foundation Hospital in Paris, France.

A 66-year-old patient underwent transplantation of an artificial endothelial implant, EndoArt, following decompensation of a penetrating keratoplasty secondary to late stromal rejection. The surgery was uneventful.

Postoperatively, three rebubbling procedures were required to achieve complete adhesion of the EndoArt.

Pachymetry decreased significantly after the EndoArt had fully attached and epithelial bullae resolved.

An Amtrix GMA was placed six weeks later due to delayed epithelial healing. In the immediate postoperative period following GMA placement, anterior segment OCT revealed early stromal necrosis with the appearance of hyporeflective lacunae, as well as an inferior descemetocele and localized detachment of the EndoArt. No signs of infectious keratitis were detected.

A new GMA inlay was performed at the descemetocele site, combined with air bubble injection to reattach the EndoArt.

Unfortunately, stromal necrosis progressed, with enlargement of the hyporeflective lacunae on anterior segment OCT and the onset of significant pain.

Given the worsening corneal condition, a repeat penetrating keratoplasty was performed, and the previous corneal graft along with the EndoArt implant were sent for bacteriological and histopathological analysis.

Stromal necrosis or melting is a potential complication of a succesful EndoArt implantation in a decompensated penetrating keratoplasty.