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Spektrum Augenheilkd (2016) 30:175–180DOI 10.1007/s00717-016-0312-y

Intraoperativemanagement ofmacroperforationsof Descemet’s membrane in deep anterior lamellarkeratoplasty

Bernhard Steger · Vito Romano · Christoph Palme · Stephen B. Kaye

Received: 10 June 2016 / Accepted: 1 September 2016 / Published online: 5 October 2016© The Author(s) 2016. This article is available at SpringerLink with Open Access.

SummaryBackground To describe a surgical approach for thecompletion of pre-descemetic deep anterior lamellarkeratoplasty (pdDALK) in the presence of a macro-perforation of Descemet’s membrane (DM).Methods Using case notes, we recorded the detailsof the intra- and perioperative course of patientswho underwent successful pdDALK in the presenceof macroperforation. A literature search of pdDALKtechniques available to the corneal surgeon in a sim-ilar scenario was undertaken.Results In two very different scenarios with intra- orpreoperative perforation of DM, a centripetal layeredlamellar dissection was performed and allowed com-pletion of pdDALK with a residual recipient centralstromal thickness of 36 and 115 µm and good visualoutcome.Conclusion Despite very different scenarios, a cen-tripetal layered lamellar dissection offers an approachfor the completion of pdDALK in the presence ofa macroperforation.

Keywords Pre-descemetic deep anterior lamellarkeratoplasty · Lamellar dissection · Descemet’s mem-

B. Steger and V. Romano contributed equally to thepreparation of this manuscript.

B. Steger, MD (�) · C. Palme,MDDepartment of Ophthalmology, Medical University ofInnsbruck, Anichstraße 35, 6020 Innsbruck, Austriabernhard.steger@i-med.ac.at

V. Romano, MDDepartment of Corneal and External Eye Diseases, St. Paul’sEye Unit, Royal Liverpool University Hospital, Liverpool, UK

S. B. Kaye, MD, FRCS, FRCOphthDepartment of Eye and Vision Science, University ofLiverpool, Liverpool, UK

brane perforation · Surgical technique · Cornealsurgery

Intraoperative Behandlung vonMakroperforationen der Descemet-Membran beitiefer anteriorer lamellärer Keratoplastik

ZusammenfassungHintergrund Es wird ein chirurgischer Ansatz zurDurchführung der tiefen anterioren lamellären Prä-Descemet-Keratoplastik (pdDALK) bei bestehenderMakroperforation der Descemet-Membran (DM) be-schrieben.Methoden Details des intra- und perioperativen Ver-laufs wurden aus Krankenakten der in die Studie auf-genommenen Patienten erhoben, bei denen erfolg-reich eine pdDALK bei bestehender Makroperforati-on der DM durchgeführt wurde. Zu den beschriebe-nen chirurgischen Ansätzen für den Hornhautchirur-gen bei vergleichbaren Szenarien wurde eine Litera-turrecherche durchgeführt.Ergebnisse Die zentripetale tiefe lamelläre Dissekti-on ermöglichte in 2 sehr unterschiedlichen klinischenSzenarien mit intra- bzw. präoperativer Perforationder DM die erfolgreiche Durchführung der pdDALKmit einer residualen Stromadicke von 36 bzw. 115 µmund gutem Visusergebnis.Schlussfolgerung Die zentripetale tiefe lamelläre Dis-sektion ermöglicht bei Makroperforationen der DM inunterschiedlichen klinischen Szenarien die erfolgrei-che Durchführung einer pdDALK.

Schlüsselwörter Prä-Descemet tiefe anteriore lamel-läre Keratoplastik · Lamelläre Dissektion · DescemetMembran Perforation · Operationstechnik · Horn-hautchirurgie

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Fig. 1 Color photographof case1 taken3monthsafter deepanterior lamellar keratoplasty. The arrowmarksaDescemet’smembraneflapcreatedbymacroperforationduring attemptedpneumatic injection. Nocorneal edema isnoted in theaffectedarea

Introduction

Deep anterior lamellar keratoplasty (DALK) has be-come a popular surgical alternative to penetrating ker-atoplasty (PK) for the treatment of keratoconus (KC)and corneal stromal pathologies [1–3]. Perforationof Descemet’s membrane (DM) during trephination,deep stromal injection of air, or dissection are knowncomplications of attempted big-bubble, Descemet-baring DALK (dDALK) [4]. While microperforationof DM commonly allows for the completion of pre-descemetic DALK (pdDALK) by lamellar dissection(LD) after decompression of the anterior chamber,macroperforations measuring more than 1 mm re-quire conversion to PK [5, 6]. In the presence ofa corneal perforation the big-bubble technique isnot possible and LD is the only surgical option [7].Although the successful completion of pdDALK hasbeen described in the presence of macroperforationof DM, the surgical approach remains unclear [8].We report an LD technique for pdDALK, which wasapplied with good results in the presence of pre- orintraoperative DM macroperforations.

Case 1

A 34-year-oldman presented with advanced KC (steepmeridian 60.4 D and flat meridian 50.9 D, thinnestpoint 223 µm) in his left eye with apical stromalscarring. His best spectacle-corrected visual acuity(BSCVA) was 20/80 OS. dDALK was attempted usingthe big-bubble technique [4]. After 7.75-mm partialthickness trephination, a small air bubble was in-jected into the anterior chamber through a temporalparacentesis. A 30-gauge bent needle was introducedbevel down into the central deep corneal stroma,

in the process of which DM was perforated tangen-tially, creating a 1.5-mm tenting tear in DM of themidperipheral cornea. The needle was retracted anda small amount of air was seen to exit from the needle-formed tunnel. Subsequently, LD was performed witha crescent blade. Firstly, a midstromal dissection wasperformed using the reflex from the air in the anteriorchamber as described by Melles. The stroma overlyingDM was then removed in a centripetal fashion fromthe area of the cornea outside of the perforation, usinga sharp crescent blade, and leaving a small approxi-mately 1.5 ×1.5 mm-thin layer of stoma covering theperforation so that the anterior chamber was main-tained. A 7.75-mm donor cornea button was strippedof DM and sutured to the recipient with partial-thick-ness interrupted 10-0 nylon sutures and a continu-ous 11-0 Prolene suture. Topical prednisolone acetate1% (Pred Forte, Allergan) and chloramphenicol 0.5%eye drops (chloramphenicol) four times a day wereused postoperatively. Postoperative examination onday 1 showed slight corneal edema in the absence ofDM detachment and a well-formed anterior chamber.The edema reduced after 1 week and the DM tear atthe perforation site was clearly visible (Fig. 1). After3 months, the patient’s BSCVA had improved to 20/40.

Anterior segment optical coherence tomography(AS-OCT, SS-1000 Casia; Tomey Corporation, Nagoya,Japan, and Spectralis HRA2; Heidelberg Engineering,Heidelberg, Germany) confirmed the dissection planeto be just anterior to DM (recipient stromal thickness36 µm) except in the perforation area, where somedeep stromal tissue had been left in place (recipi-ent stromal thickness 124 µm; Fig. 2). The corneawas clear and no edema was noted in the area ofthe DM tear. Endothelial cell density (ECD) of thecentral cornea assessed using in vivo confocal mi-croscopy (IVCM, Heidelberg Retina Tomographer IIwith Rostock Cornea Module; Heidelberg Engineer-ing, Heidelberg, Germany) 3 months after surgery was2,706 ± 22 cells/mm2 at a focal depth of 496 µm withsome polymegathism.

Case 2

A 31-year-old man was referred with a history ofa perforated left corneal ulcer secondary to bilateralrosacea keratitis and iris plugging of the corneal per-foration. He had had repeated corneal glueing over1 year prior to referral, but the leak kept recurring.He presented with a corneal scar with thinning andspontaneous leakage at the site of perforation withthe iris adherent to and around the wound (Fig. 3a).VA was 6/12 with a pinhole. After 7.5-mm partialthickness trephination of the recipient cornea, lamel-lar dissection was performed with a crescent blade.An air infusion was used to maintain the anteriorchamber. The perforation site was spared until com-pletion of the centripetal dissection of the unaffectedposterior corneal stroma surrounding the edge of the

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Fig. 2 aAnterior seg-mentoptical coherencetomographyof case1show-ing the site ofDescemet’smembraneperforation.bLamellar dissectionwasperformed to the level ofpre-descemetic stromal layers inthecenter andmoreanteriorin theperforationarea

Fig. 3 aPreoperativecolor photographof case2takenafter instillationofadropof 2%fluoresceineyedropsshowingactivespontaneous leakage fromacorneal scar;b6monthsafter deepanterior lamellarkeratoplasty, thegraft isclear, an iris strand remainsadherent to theperforationsite

perforation as in case 1. The iris strands remainedadherent to the posterior edges of the perforation.A 7.75-mm donor cornea button was stripped of DMand sutured to the recipient bed with partial-thick-ness, combined, interrupted 10-0 nylon sutures anda continuous 11-0 Prolene suture. Postoperative top-ical treatment was identical to case 1. Clinical exam-ination on day 1 showed mild corneal edema and nodouble anterior chamber. The cornea cleared over thefollowing 4 weeks and at 6 months BCVA was 20/32.The iris remained at the edges of the former per-foration site (Fig. 3b). AS-OCT confirmed a central115-µm pre-descemetic stromal layer and a 29-µmscarred stromal layer at the perforation site (Fig. 4).IVCM was performed and confirmed traction foldsin DM caused by the attached iris strands with ab-sent endothelial cells in this region (Fig. 5). Intactendothelial cells were found starting at a distance of

600 µm from the perforation site. Central ECD was2,421 ± 18 cells/mm2 using IVCM at a focal depth of568 µm.

Discussion

dDALK has a long learning curve and a high rate ofDM perforation, occurring in between 4.4 and 39%of cases [8–11]. Microperforations may not always benoticed intraoperatively and may be associated withslow leakage or “sweating” of aqueous liquor throughthe exposed DM and can result in the postoperativedevelopment of DM detachment [12, 13]. Macro-perforations, however, are readily seen because of animmediate loss of anterior chamber stability, and of-ten require surgical conversion to PK [14]. There havebeen several reports on the successful completion ofpdDALK in the presence of a perforation of DM [5,

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Fig. 4 Anterior segmentoptical coherence tomogra-phy incase2 taken6monthsafter deepanterior lamel-lar keratoplasty confirmingtheanatomic level of lamel-lar dissection in immediateproximity to theperforationsite andan iris strandadher-ent to theperforation

Fig. 5 In vivo confocalmicroscopyof theperfo-ration site in case2 taken6monthsafter deepanteriorlamellar keratoplasty. Trac-tional folds inDescemet’smembraneexertedby theattached iris strandcanbeseen. Noendothelial cellsarepresent in thecenter, butcanbeseen in theperipheryof the imageat ameasureddistanceof 600μm from theperforation site

8, 9, 11]. To date, no safe and reproducible strategyhas been offered to the corneal surgeon on how toapproach such cases.

We report a centripetal layered lamellar dissectiontechnique for pdDALK, which was applied with goodoutcome in two patients with pre- or intraoperativemacroperforation of DM. A schematic illustration ofthe described technique is given in Fig. 6.

In the first case, LD was possible to the level of thepre-DM stroma. This was possible because the ante-rior chamber was well maintained with air in spiteof macroperforation. The estimated needle tunnellength of approximately 3 mm from the entry site tothe perforation prevented major air or aqueous leak-age from the anterior chamber and thus allowed thecontinuation of pdDALK, which is less likely to be suc-cessful if the anterior chamber is lost and the eye issoft secondary to an open DM perforation as duringtrephination. Secondly, visualization was crucial forthe avoidance of both the needle tunnel and the perfo-

ration site during LD. This was only possible becauseDM was perforated before attempted pneumodissec-tion, as stromal emphysema would have preventedthe visualization of deeper structures. For LD in casesof failed big-bubble formation but intact DM, Anwaret al. suggested using a blunt scissors for LD ratherthan the crescent blade to reduce the risk of DM per-foration at later stages of the procedure [14]. Thismethod is described by the authors as being quickerthan LD using a crescent blade, time being an impor-tant surgical parameter besides difficulty and safety.We believe that the use of blunt corneal scissors maybe a valuable modification to our described approach,although there is a risk of distortion of the tissues us-ing scissors, which may rent open the perforation. Inaddition, changing from a deeper lamellar plane, how-ever, in the first dissected “safe zone” to a more su-perficial one at the perforation site may prove difficultwith blunt scissors and, therefore, still require the useof a crescent blade.

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Fig. 6 Illustrationof thesurgical techniqueapplied incentripetal layered lamellardissectionpdDALK.aCornealmeltwithDMperfo-ration. An intraocularairbubble isusedtomaintain theanteriorchamber. Dependingontheextentandarchitectureof theperforation,air infusionmayberequired. bPartial-thicknesstrephinationtotheposteriorcornealstroma. cPeripheralandcentripetal lamellardis-sectiontothelevelofthepre-descemeticposteriorstroma.dThedissectionlayer ismovedtoamoreanteriorstromalplanecommenc-ingatadistanceof1.5mmto theperforationsite. eThedissectedcorneal tissue is removed, avoidingmanipulationof theperforationsite,whichremainscoveredbyavariableamountofposteriorstromal tissuedependingonthesizeandarchitectureof theperforation.fAdonor cornea strippedofDM is sutured into theprepareddonorbed.DMDescemet’smembrane

In the second case, pdDALK was performed fora Seidel-positive corneal scar secondary to a perfo-rated corneal ulcer. Delaying surgery by managementwith a bandage contact lens until subsidence of in-flammation allowed for a more controlled setting andelective as opposed to tectonic therapeutic pdDALK.Keratoplasty in an acutely inflamed eye – besidesother known risk factors like corneal neovasculariza-tion, young recipient age, repeat corneal transplants,and gender mismatch – is associated with decreasedlong-term graft survival [15–18]. Intraoperativelythe perforation site was plugged by iris strands withsurrounding anterior synechiae, which allowed foranterior chamber stability during LD. The cornealmelt at and around the perforation site made it im-possible to choose a more superficial plane duringthe LD. This resulted in an inverse recipient stromalthickness profile in postoperative AS-OCT comparedwith the first case, being very thin at the perforationand thicker in the safe zone. Ongoing leakage andreduced anterior chamber stability during the pro-cedure made LD more difficult, also explaining thefailure to expose DM or the pre-descemetic stroma.

LD pdDALK with the aim of exposing DM is time-consuming and difficult, explaining the high con-version rate to PK in the presence of DM perfora-tion. While avoidance of perforation in the first placeshould be the principal goal, this highlights the needfor a feasible and reproducible surgical approach tosuch cases. In the cases presented here, an LD ofthe recipient stromal bed facilitated the completion

of pdDALK. Although the recipient stromal bed thick-ness measured 35 and 100 µm postoperatively, bothpatients regained good BCVA. This is in line with a re-cent report, describing a time-dependent improve-ment of visual acuity in pdDALK in the long termwith equally good visual outcome compared withdDALK [3]. This supports our notion that, especiallyin the presence of DM perforation, safe completion ofpdDALK should be given a higher priority than baringof DM. Additionally, the lack of endothelial rejectionand the better long-term endothelial cell survival arelikely to allow for a longer graft survival after pdDALKcompared with PK. In the presented cases, a goodECD was measured 3 and 6 months after pdDALK inspite of paracentral DM macroperforation.

In conclusion, despite very different scenarios,a centripetal layered lamellar dissection offers an ap-proach to the completion of pdDALK in the presenceof a macroperforation.

Open access funding provided by University of InnsbruckandMedical University of Innsbruck.

Conflict of interest B. Steger, V. Romano, C. Palme, andS.B. Kaye declare that they have no competing interests.

Open Access This article is distributed under the terms ofthe Creative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which per-mits unrestricted use, distribution, and reproduction in anymedium, provided you give appropriate credit to the origi-nal author(s) and the source, provide a link to the CreativeCommons license, and indicate if changes were made.

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