Partial descemetorhexis for delayed Descemet membrane detachment following penetrating keratoplasty, suggestion of a pathomechanism

Abstract

Purpose to report a case of delayed Descemet membrane detachment (DMD) 45 years after penetrating keratoplasty (PK) for keratoconus and its management with a partial descemetorhexis after failed air/gas descemetopexy. A pathomechanism of DMD is proposed based on the anatomic appearance of the DMD and the success of descemetorhexis. Observations a 60-year old male presented with acute corneal edema of his left eye 45 years after successful PK for keratoconus. Anterior segment ocular coherence tomography (AS-OCT) revealed a wide area of DMD without a visible tear. Reattachment was tried using air and gas descemetopexy with only temporary success. A partial descemetorhexis was then performed just centrally to the graft-host interface and only in the detached area followed by injection of gas bubble. Complete reattachment of Descemet membrane (DM) on the 1st post-operative day was achieved. This anatomical success was maintained 3 months post-surgery and accompanied by decrease of central corneal thickness, however with uncomplete restoration of visual acuity. Conclusion delayed DMD following KP for keratoconus should be differentiated from acute graft rejection. It could be a result of Descemet tear, but in some cases and despite careful observation of AS-OCT no tear could be seen. In such cases, a tractional detachment of DM might be the underlying pathomechanism and descemetorhexis could help manage it. This new surgical approach might help avoid a re-keratoplasty. Importance This is the first case report describing success of partial descemetorhexis as a surgical management option for delayed DMD and suggesting a pathogenesis based on this success. This might help avoid re-keratoplasty as a management of this rare complication.