Transcript Irido-Corneal Adhesions Following Descemet Stripping

Irido-Corneal Adhesions and Fibrous
Ingrowth into the Graft-Host Interface
Causing Graft Failure in a Case of
Descemet Stripping Automated
Endothelial Keratoplasty
Andrew Greenberg, M.D.
Michael Ehrenhaus, M.D.
SUNY Downstate Medical Center, Brooklyn, NY
The authors have no financial interest to disclose.
Introduction
• Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) is a
relatively new procedure replacing deceased or malfunctioning endothelial
tissue with that of a healthy donor.
• Complications associated with this technique that are being elucidated
include:
– Irido-corneal graft adhesions
– Fibrous ingrowth within the graft-host interface
– Graft failure
• Currently, an incidence of graft failure secondary to irido-corneal adhesions
or ingrowth has not been described in the literature.
Case
• A 68-year-old man with a history of chronic angle closure glaucoma and
benign prostatic hypertrophy on tamsulosin presented with blurred vision in
his left eye January 2007.
• Patient was diagnosed with Fuchs endothelial dystrophy, mild corneal
edema, narrow angles and cataracts. A superior iridotomy was noted to be
patent, performed by the referring physician.
• One month later, the patient developed increased corneal edema and mild
bullous keratopathy.
• In March 2007, the patient underwent uncomplicated cataract extraction
with intraocular lens placement.
Case
• In May 2007, DSAEK was performed on the patient’s left eye without
complications, using a similar technique described by Terry et al3 .
• Preoperative BCVA was 20/400.
• The patient was followed every one to two weeks during the initial postoperative period and then monthly to asses his recovery.
• In postoperative month 7, the patient developed temporal irido-corneal
adhesions that eventually involved the peripheral graft and also caused iris
traction and correctopia.
Case
• BCVA decreased
significantly with
increasing corneal haze
(figure 1 and 2).
Figure 1
• The graft eventually
failed
Figure 2
Case
• A repeat DSAEK procedure was performed in March of 2008.
• Intra-operatively, a fibrous growth was discovered originating from the
peripheral iris and was noted to have grown within the graft-host interface.
An iridodialysis adjacent to the peripheral iridotomy was noted as well.
• The fibrous tissue ingrowth was cut and excised, and the posterior corneal
surface was carefully polished of any residual scar tissue.
• The iridodialysis was re-apposed to the angle with a double armed10-0
prolene suture anchored to sclera, providing more stability of the iris tissue
and a deeper and more stable anterior chamber for the remainder of the
surgery.
• The remainder of surgery was uneventful, and the new DSAEK graft was
placed without complication.
Results
• Post-operative month 8: the slit
lamp exam shows no corneal
haze, a clear cornea, a lack of iris
adhesions to the graft, a
centralized pupil, and a deep
anterior chamber (Figure 3,4).
Figure 3
• UCVA is 20/25
Figure 4
Discussion
• Descemet’s stripping automated endothelial keratoplasty (DSAEK) is still a
relatively new procedure. With it’s increasingly widespread acceptance,
there are new intra-operative and post-operative complications that need to
appropriately managed.
• A leading complication discussed in the literature is graft failure, but the
complications of irido-corneal interaction has not been elucidated as of yet.
• Several aspects of this patient’s conditions may have rendered him
susceptible to graft failure including:
– An iridodialysis and the use of tamsulosin (for benign prostatic hypertrophy)
creating a floppy iris tissue segment resulting in iridocorneal touch
– The narrowing of the anterior chamber angle secondary to chronic angle
closure glaucoma
Discussion
• The creation of a preoperative iridotomy or intra-operative iridectomy may
play a key role in increasing the depth of the chamber and therefore
lessening the interaction between the iris and cornea
– Iridotomy is often used to prevent the pupillary block which may occur secondary to the
air injection into the anterior chamber used to maintain the donor tissue in place against
the donor cornea
• The effects of tamsulosin on iris laxity during cataract surgery has been
elucidated by Chang et al. However, its effects on corneal transplant
procedures including DSAEK [and penetrating keratoplasty] have not been
investigated.
• In this case, fibrinous invasion from the iris tissue, into the graft-host
interface was the key reason in causing graft failure.
– This has been noted in 2 other cases as well, resulting in graft failure one of the cases so
far.
Conclusion
• Specific attention needs to paid to the tissue-graft edges, including any
irido-corneal adhesions.
• Tamsulosin usage may play a pivotal role in intra-operative complications
and therefore possibly even graft failure due to extra manipulations that
may be warranted during the DSAEK procedure.
• Repeat DSAEK with lysis of all iris adhesions, careful cleaning of the
posterior stroma, and repair of any iridodialysis or other iris abnormalities,
is a proper treatment for repairing a failed DSAEK graft due to an unusual
presentation of fibrinous ingrowth into the graft-host interface.
Bibliography
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5.
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