Masked Neurotrophic Keratitis In A Decompensated Cornea Following Descemet Stripping Automated Endothelial Keratoplasty (Dsaek) Presenting With Intact Epithelium

To present an interesting case of neurotrophic keratitis in a patient with primary graft failure after DSAEK, presenting with an intact epithelium . 

Cornea Department, General Hospital of Athens “G.Gennimatas”, Athens, Greece, a tertiary eye-care center. 

A 75-year-old male with Fuchs endothelial corneal dystrophy and prior cataract surgery presented with decreased vision in his left eye (counting fingers). He underwent uncomplicated DSAEK and was treated postoperatively with topical antibiotics and steroids. One week later, the graft was fully attached, but corneal stromal edema persisted. Follow-up's at 2, 4, and 6 weeks showed no improvement and no signs of rejection. Persistent edema despite a well-attached graft indicated primary graft failure; for this reason a repeat endothelial keratoplasty was recommended.

 However, the patient did not wish to undergo another surgical procedure. One year later, the patient returned expressing a desire to undergo surgery, as he was experiencing difficulties in his daily activities.For this reason, a regrafting procedure was scheduled. In the operating room, at the start of the surgery and upon removal of the epithelium, four neurotrophic ulcers were revealed, which had not been visible on slit-lamp examination during the preoperative evaluation. DSAEK was postponed and the patient treated with intense topical lubrication and antibiotic drops. Notably, four days later, the epithelium had completely healed. A penetrating keratoplasty (PK) was scheduled for the near future. 

Masked neurotrophic keratitis may exist in a decompensated cornea post-DSAEK. The decompensated cornea may exacerbate neurotrophic effects, even in the absence of epithelial breakdown. Early recognition and ocular surface optimization can prevent progression to ulceration or perforation and allow safer subsequent regrafting.