Title: Dislocation of the DSEK Donor Graft into the Posterior Segment An Intraoperative Complication in DSEK Surgery
1Dislocation of the DSEK Donor Graft into the
Posterior SegmentAn 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
2Introduction
Anterior chamber OCT showing a well adhered DSEK
graft
- Descemets 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
3Methods
- 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
4Case 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
5Case 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
6Case 2 Two months after repeat DSEK, the new
donor graft is well-adhered. A healed scleral
incision is seen superotemporally
7Case 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 IA 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
8Case 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
9The 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
10Results 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
11Results 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 IA
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
12Conclusions
- 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