Purpose:
To evaluate outcomes and graft survival of Descemet membrane endothelial keratoplasty (DMEK) for failed penetrating keratoplasty (PK).
Methods:
Ninety-three DMEK procedures performed in 84 eyes of 77 patients with failed PK were retrospectively reviewed. The main outcomes were corrected distance visual acuity and graft survival assessed with Kaplan–Meier survival analysis and proportional hazards modeling taking follow-up into consideration.
Results:
Sixty-nine eyes had 1 previous failed PK, 13 had 2, 1 had 3, and 1 had 4. Ten eyes had failed Descemet stripping endothelial keratoplasty (DSEK) performed under failed PK. Fourteen cases (15%) had previous glaucoma filtration surgery (9 trabeculectomy alone; 5 trabeculectomy and aqueous shunt). Median follow-up was 21 months (range, 1 month to 7 years). Median Snellen corrected distance visual acuity improved from 20/100 preoperatively (range, 20/30 to count fingers) to 20/30 at 6 months postoperatively (n = 73; range, 20/20–20/200). Rebubbling rates were 53% when the diameter of the DMEK graft was oversized, 27% when same sized, and 33% when undersized relative to that of the previous PK graft. Two grafts (2%) experienced an immunologic rejection episode, and 15 (16%) failed, including 5 primary/early failures and 10 late failures. Previous glaucoma surgery was the only significant risk factor for failure (relative risk, 7.1; 95% confidence interval, 2.1–37.0). The 1-, 2-, and 3-year graft survival rates were 96%, 89%, and 89% without versus 78%, 53%, and 39% with previous glaucoma surgery.
Conclusions:
Treatment of failed PK with DMEK produced similar 4-year survival (76%) and better visual outcomes than previously reported with Descemet stripping endothelial keratoplasty or an initial PK regraft.
A 22-year-old male patient presented in 1988 with active vernal keratoconjunctivitis. He was treated with topical mast cell stabilisers and corticosteroids. Chronic inflammation despite topical treatment necessitated oral immunosuppressants. Active disease came under control with this; however, the patient gradually developed limbal stem cell deficiency. He underwent bilateral pannus resection with amniotic membrane transplantation that resulted in improved ocular surface. In 2007, patient was found to have significant bilateral posterior subcapsular cataracts and underwent bilateral cataract surgery with intraocular lens implantation with good visual outcome. In 2016, he was provided with scleral lens prosthetic device, which further improved vision. At last follow-up, more than 25 years after his initial visit, his visual acuity was 20/25 in both eyes with a stable surface. With a comprehensive approach using immunosuppression, surgical therapy and scleral lens prosthetic device, chronic vernal keratoconjunctivitis can be well managed as illustrated in this case.
Corneal ocular surface squamous neoplasia usually begins at the limbus and presents as an avascular translucent sheet over the corneal surface. This case report describes a 67-year-old man with an unusual isolated, keratinous nodular corneal lesion. Slit-lamp examination showed an elevated, avascular, whitish plaque-like lesion at the central cornea surrounded by a normal corneal epithelium, with reduced visual acuity of 20/200 in the right eye. Anterior segment optical coherence tomography displayed a hyper-reflective, thickened epithelium with back shadowing. Histopathology showed keratinising hyperplastic stratified squamous epithelium with parakeratosis and moderate nuclear pleomorphism in lower second/third of epithelium suggestive of moderate dysplasia. His visual acuity returned to 20/20 after surgical excision but he developed multifocal corneal recurrences 6 weeks later, which were successfully managed with seven cycles of topical interferon immunotherapy. There are no recurrences observed at 6 months of follow-up.
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