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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.

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Page 1: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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.

Page 2: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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.

Page 3: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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.

Page 4: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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 post-operative 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.

Page 5: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

Case

• BCVA decreased significantly with increasing corneal haze (figure 1 and 2).

• The graft eventually failed

Figure 1

Figure 2

Page 6: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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.

Page 7: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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).

• UCVA is 20/25

Figure 3

Figure 4

Page 8: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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

Page 9: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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.

Page 10: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

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.

Page 11: Irido-Corneal Adhesions and Fibrous Ingrowth into the Graft-Host Interface Causing Graft Failure in a Case of Descemet Stripping Automated Endothelial

Bibliography1. Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter

evaluation of cataract surgery in patients taking tamulosin (flomax). Ophthalmology 2007; 114, 957-64

2. Gorovoy MS, Descemet-stripping automated endothelial keratoplasty. Cornea 2006; 25:886-9

3. Leejee SH, Yoo SH, Deobhakta A, Donaldson KE, Alfonso EC, Culbertson WW, O’brien TP. Complications of descemet’s stripping with automated endothelial keratoplasty: survey of 118 eyes at one institute. Ophthalmology 2008; 115,1517-24

4. Price MO, Price FW. Descemet’s stripping with endothelial keratoplasty: comparative outcomes with microkeratome-dissected and manually dissected donor tissue. Ophthalmology 2006; 113, 1936-42

5. Terry MA, Shamie S, Chen ES, Hoar KL, Friend DJ. Endothelial keratoplasty: A simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block. Ophthalmology 2007; 115:1179-86