Transcript An Intraoperative Complication in DSEK Surgery

Dislocation of the DSEK Donor Graft into the
Posterior Segment
An Intraoperative Complication in DSEK Surgery
Mark M Fernandez MD, Mark S Gorovoy MD, George OD
Rosenwasser MD, Terry Kim MD, Alan N Carlson, MD, and Natalie A
Afshari MD
Financial Disclosures:
Dr. Gorovoy has a relationship with Harvey Instruments
Dr. Rosenwasser is a paid lecturer for Allergan, Vistacon and Inspire
Dr. Afshari has a research grant from Reseach to Prevent Blindness
Drs. Fernandez, Kim and Carlson report no financial interests
Introduction
Anterior chamber OCT showing a well adhered DSEK graft
• Descemet’s stripping endothelial keratoplasty (DSEK) is rapidly
becoming the preferred treatment for corneal edema due to
endothelial dysfunction
• DSEK surgery is also being conducted in eyes with prior
vitrectomy
• We present a series of DSEK graft dislocations into the posterior
segment
Methods
• Four cases of
intraoperative DSEK
graft dislocation into the
posterior segment were
identified
• The surgical
management, and the
final outcome of each
eye are discussed
A DSEK graft dislocated posteriorly
Case 1:
• A 59 year old woman with a sutured sulcus intraocular lens and
history of pars plana vitrectomy underwent DSEK surgery for
decompensation of her fourth full thickness corneal graft
• As the donor graft unfolded within the anterior chamber, it
slipped through a hole in the posterior capsule and entered the
posterior segment
• Attempts to float the graft using irrigation were unsuccessful, so
incisions were closed
• Seven days later she underwent pars plana vitrectomy to
remove the graft from the posterior segment as well as full
thickness penetrating keratoplasty
Case 2:
• A 62 year old man with Fuchs dystrophy underwent DSEK
surgery three months after phacoemulsification with anterior
vitrectomy and sulcus intraocular lens placement
• The donor graft was inserted into the anterior chamber and
unfolded uneventfully; filtered air was inserted into the anterior
chamber and the DSEK graft could no longer be visualized
• A superotemporal sclerotomy was made by a vitreoretinal
surgeon; the donor graft was seen laying on the surface of the
macula and was removed. It was then repositioned in the
anterior chamber
• The graft remained attached postoperatively, but it did not clear.
Two months later, repeat DSEK surgery was performed
Case 2: Two months after repeat DSEK, the new donor graft is welladhered. A healed scleral incision is seen superotemporally
Case 3:
• A 63 year old man with a failed penetrating keratoplasty,
aphakia, only remnants of an iris rim, and prior pars plana
vitrectomy underwent secondary scleral sutured posterior
intraocular lens placement, followed by a DSEK one month later
• During DSEK surgery, the graft dislocated posteriorly around the
sutured posterior chamber intraocular lens during unfolding with
the irrigator/aspirator (see supplemental video)
• Using the I&A handpiece, the graft was maneuvered around the
sutured posterior chamber IOL into the anterior chamber and
repositioned
• Post-op day one revealed a dislocated donor graft. The patient
underwent a penetrating keratoplasty two weeks later
Case 4:
• A 79 year old woman with history of traumatic open globe, pars
plana vitrectomy, trabeculectomy, Ahmed valve, sutured
posterior chamber lens and a failed large diameter corneal graft
underwent DSEK surgery
• Upon opening, the globe began to collapse. Air was used to
maintain the anterior chamber. The graft was inserted and the
globe was refilled with balanced salt solution
• Air was injected to unfurl the graft. Despite attempts to hold it in
the anterior chamber, the graft slipped between the lens implant
and ciliary body into the posterior segment
• A pars plana vitrectomy was performed nine days later to
remove the graft. Two months after, a penetrating keratoplasty
was performed
The gray-colored donor graft
is held in place centrally with
a Sinskey hook while air is
inserted into the anterior
chamber
The graft is seen
within the anterior
chamber moments
before it slips into
the posterior
segment
Shortly after, the graft
has dislocated into
the posterior segment
and is no longer
visible
Results: Patient and Intraoperative Risk Factors
• All eyes had undergone anterior or pars plana vitrectomy
between three months and several years prior to surgery
• All eyes had undergone complicated intraocular lens placement
prior to DSEK surgery; All IOLs were in the posterior chamber.
Three were sutured and one was a sulcus IOL
• In two cases, the graft dislocated as it unfolded within the
anterior chamber
• In two cases, dislocation occurred after injection of sterile air
within the anterior chamber
Results: Surgical Management
• Of the four cases reported, one eye underwent successful
repeat DSEK and the other three underwent successful PK
following graft removal
• In two cases the misplaced graft was subsequently repositioned
and remained at least partially attached. Both grafts failed and
were repeated within two months
• In one case the graft was retrieved using the I&A handpiece. In
three cases a vitreoretinal surgeon was consulted to remove the
graft
• Satisfactory visual results were attained after the complication
was addressed in each case
Conclusions
• Dislocation of donor grafts to the posterior segment is a rare
complication of DSEK surgery that appears to require repeat
corneal grafting, however good final results can be obtained
• This complication must be considered in the preoperative
planning of DSEK surgery in vitrectomized eyes, especially those
with other risk factors for posterior dislocation like aphakia,
pseudophakia with open posterior capsule, and sutured IOL
• Although access to a vitreoretinal surgeon for the removal of
posterior segment grafts is ideal, in some circumstances the
problem can be addressed using tools available for anterior
segment surgery