Endothelial Keratoplasty without Descemet’s Membrane Stripping: Histologic and Ultrastructural Findings

Abstract

Aim: To report histologic and ultrastructural findings of endothelial keratoplasty (EK) performed without Descemet’s membrane stripping. Methods: Clinical techniques, histology, and transmission electron microscopy. Results: A 55-year-old woman was referred to us, after 2 unsuccessful penetrating keratoplasties (PKs), for pseudophakic bullous keratopathy. An 8.0-mm EK without Descemet’s membrane stripping was performed, and clarity was restored to the failed penetrating regraft. A year later, the lamellar graft failed, and a third PK was performed for intractable corneal edema. Light microscopy of a semi-thin section of the trephined corneal button showed both the recipient’s and the donor’s Descemet’s membrane, the well-preserved structure of the full-thickness graft, and marked edema of the adherent stromal carrier of the endothelial transplant. The host endothelium was absent at the interface, and the donor endothelium was atrophic. Electron microscopy revealed regularity and even spacing of collagen fibrils as well as quiet keratocytes on both sides of Descemet’s membrane at PK-EK interface. Conclusion: These findings suggest a lack of proliferation and hypercellular scarring, and offer further support to the already proven merits of EK.

Endothelial keratoplasty without stripping the Descemet's membrane

“…However, isolated cases published in the literature support the feasibility of EK without stripping the DM in patients with failed grafts 1 2. Based on our observation of favourable outcomes after EK without stripping the DM in patients with no clinical evidence of DM pathology, we hypothesise that Descemet's stripping may be an avoidable intraoperative step in EK for the indications where it is expected to be normal and optically clear.…”

“…Several observations provide evidence towards this hypothesis 1. Histological study of failed Descemet's stripping endothelial keratoplasty buttons has shown that the presence of residual DM was not associated with any alteration in cellularity or inflammation 2 3…”

Microscope Integrated Optical Coherence Tomography Guided Descemet Stripping Automated Endothelial Keratoplasty in Congenital Hereditary Endothelial Dystrophy

“…There are various intra-operative difficulties in performing EK in CHED patients which include poor visibility due to very severe corneal oedema in these cases 13 and strong adherence of the Descemet membrane to the underlying stroma which could result in DM retention and graft failure. 21 Stripping of DM is much easier in decompensated corneas due to other causes such as Fuch’s endothelial dystrophy (FECD) in contrast to the CHED eyes. 22 This might result in residual DM remnants which would hinder the graft apposition.…”

A review of techniques and outcomes of endothelial keratoplasty in congenital hereditary endothelial dystrophy

“…Performing EK in CHED patients is associated with various intraoperative difficulties: poor visibility due to severe corneal edema and strong adherence of the DM to the underlying stroma, which may result in DM retention/tags, leading to graft detachment and failure. [ 15 16 ] DM scoring is found to be much simpler in decompensated corneas such as Fuchs’ endothelial dystrophy in contrast to the CHED eyes. [ 17 ]…”