Transcript Grand Rounds - ASCRS/ASOA 2009

Posterior Dislocation of an Endothelial
Keratoplasty Donor Lenticule in Pseudophakia
Reecha Sachdeva, MD1
Ricardo N Sepulveda, MD1
Mark R Barakat, MD1
Lynn Schoenfield, MD2
Jonathan E Sears, MD1
William J Dupps, Jr, MD, PhD1,3,4
1Cole
Eye Institute, 2Department of Anatomic Pathology,
3Biomedical Engineering, 4Transplant
Cole Eye Institute
9500 Euclid Avenue Cleveland, OH 44195
Abstract Poster Presentation
The American Society of Cataract and Refractive Surgery
April 4, 2009
Dr. Dupps recieved a travel reimbursement from Reichert.
The remaining authors have no financial interest in the subject matter of this poster.
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Purpose
To describe the management of a posteriorly
dislocated DSAEK graft and discuss possible
risk factors which may lead to this rare
intraoperative complication
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Methods: Patient Presentation
A 72 year old female with glaucoma and diabetes presented for corneal
evaluation:
Past Ocular History:
9 years prior to presentation: complicated cataract surgery with resultant
decentered anterior chamber intraocular lens with superior haptic encapsulated by
iris scarring, dense phimosis of the capsular remnants, and fixed pupillary aperture
with a large superotemporal iris defect. Intraocular pressure at that point was
controlled on maximal medical therapy. Visual acuity was limited to count fingers at
two feet.
7 years prior to presentation: A lens exchange was performed, employing a
trans-scleraly sutured intraocular lens, along with pars plana vitrectomy and
implantation of a posteriorly positioned Ahmed glaucoma tube shunt. Post-operative
examination initially revealed a well-positioned intraocular lens and glaucoma
implant with a superior pupillary defect, well-controlled intraocular pressure off all
glaucoma medication, and a best corrected vision stabilized at 20/25.
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Methods: Patient Presentation
Upon presentation to Cole Eye Institute for Corneal evaluation:
Patient with BSCVA 20/80 in the involved right eye.
Examination revealed pseudophakic bullous keratopathy.
Subsequently, a Descemet’s stripping endothelial keratoplasty
(DSAEK) was performed.
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Methods: Complication
DSAEK in the right eye:
The intraoperative course was complicated by spontaneous inversion
and unfolding of the donor graft with endothelium facing upward.
Immediately after the graft’s orientation was corrected and prior to
placement of the air bubble, the fully unfolded graft migrated rapidly
through the iris defect toward the tube and into the vitreous cavity.
The incision was closed in preparation for pars plana retrieval of the
lenticule and repeat DSAEK with new donor tissue.
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Methods: Complication
The patient was re-examined the following day, revealing significant corneal
edema and the donor lenticule lying on the inferior, extramacular retina.
Figure 1
Figure 2
Figures 1 and 2: Donor lenticule found outside the inferotemporal arcade. Retinal pigment
epithelium changes within the macula due to previous photocoagulation for diabetic macular edema.
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Results: Management
The donor lenticule was retrieved two weeks later by a pars plana
vitrectomy and withdrawn by extending a sclerotomy. The
lenticule was found unfolded, endothelial side up, adherent to
the retina in a extramacular location.
Figure 3: Elevation of the
adherent corneal tissue with a
Michels pick.
Figure 3
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Results: Management
Figure 4: Retrieved corneal tissue with intact Descemet’s membrane
and stromal edema. No evidence of inflammation or scar formation.
Figure 4
Posterior Dislocation of an Endothelial Keratoplasty Donor Lenticule in
Pseudophakia
Results: Management
DSAEK was repeated through the pre-existing corneal wound with
modifications to prevent repeat dislocation:
A Keith needle on a 10-0 prolene suture was passed from the nasal
limbus across the anterior chamber and through the temporal wound.
The needle was then passed through the edge of the donor tissue, the
graft folded in a 60/40 configuration, and the needle was passed back
into the wound and across the anterior chamber out a second exit point.
The suture ends were then clamped, and slack was taken up by the
assistant as the graft was inserted. After pressurization of the anterior
chamber with continuous air infusion between 30 and 60 mm Hg for
several minutes as previously described,1 the prolene suture was removed.
1 Meisler
DM, Dupps WJ, Covert DJ, Koenig SB. Use of an air-fluid exchange system to promote graft
adhesion during Descemet’s stripping with automated endothelial keratoplasty (DSAEK). J Cataract
Refract Surg 2007;33(5):770-2.
Posterior Dislocation of an Endothelial Keratoplasty Donor
Lenticule in Pseudophakia
Results: Outcome
On the first postoperative day, the graft was fully attached. Six months
later, the graft remains attached with a best-corrected vision of 20/60.
Figure 5: External photograph
revealing attached, clear graft
and corneal wound.
(postoperative day #1)
Figure 5
Discussion
To our knowledge, this is the first case of posteriorly dislocated endothelial graft in a
pseudophakic eye.
This rare complication may have been related to several risk factors:
-
large pupil
iris defect
absence of zonules and capsular support
absence of the anterior hyaloid due to previous vitrectomy
The pars plana tube was located in the region of the iris defect and seemed to provide an
intraocular current that led to initial inversion of the graft and ultimate posterior
dislocation.
Also, the orientation of the IOL haptics and fixation sutures relative to the iris defect
and the pars plana tube may have been contributory. The haptics were oriented along a
superonasal-inferotemporal meridian formed by the axis of fixation—perpendicular to
the meridian of the glaucoma implant and to a hemi-meridian with a large iris defect.
This configuration provided no haptic barrier to graft migration in the region of the iris
defect and would have allowed the IOL to tilt on its fixation axis, yielding to the
migrating graft in a trap door fashion and enhancing access to the vitreous cavity.
Posterior Dislocation of an Endothelial Keratoplasty Donor Lenticule in Pseudophakia
Discussion
Subsequent management of the dislocated graft highlighted several points of interest.
- Suturing the lenticule during this procedure in the manner described adds
safety in eyes with several pre-existing conditions (please refer to previous slide for
risk factors).
- The tight adherence of the lenticule to the retina was likely due to the tissue
being fully unfolded with the endothelium side up, creating a vacuum
between the donor tissue and the retina perhaps by way of its physiologic
pump mechanism. This finding suggests that early retrieval is necessary
because there is a chance that it could adhere to the fovea. Additionally,
while there was no evidence on histopathology of scar formation (Figure 4),
it stands to reason that leaving foreign tissue closely apposed to the retina
over time would lead to inflammation with subsequent fibrosis and a more
difficult surgical repair.
- The posterior view through a cornea two weeks after removal of its
endothelium was surprisingly clear after intensive administration of topical
steroids.