A 72-year-old male with a history of long standing diabetes mellitus type 2 and dry eye presented to the Cornea Department with a 2-month history of decreased visual acuity and mild discomfort of the right eye. Upon examination, visual acuity was 20/80 OD and 20/40 OS. Biomicroscopy revealed adequate eyelid closure in both eyes with meibomian gland dysfunction. Tear meniscus was less than 1
mm and tear break-up time less than 7 seconds. The right cornea demonstrated superficial punctate keratitis, stromal edema, and a midperipheral 2
mm wide epithelial defect and corneal thinning of 80% with no signs of infectious disease. The anterior chamber had no signs of inflammation and a posterior chamber intraocular lens was placed in the capsular bag. Corneal aesthesiometry was marginally decreased in OD. The left cornea had mild inferior punctate keratitis and mild nuclear sclerosis in lens. Schirmer II test showed 5
mm and 12
mm OD, and OS respectively. The rest of the ophthalmologic exam was within normal limits. Initial workup included superficial scrapings for PCR for HSV-1, HSV-2, and VZV; also Rheumatoid Factor, antinuclear antibodies, anti-SSA, anti-SSB, anti-CCP, anti Hepatitis C, p-ANCA, and c-ANCA. All results were negative or within normal limits. He was initially managed with topical unpreserved lubricant (Lagricel Sodium Hyaluronate 0.4%, Sophia laboratories, Guadalajara, Mexico) and 20% autologous serum drops QID. The epithelial defect healed adequately and vision improved to 20/60. Eight weeks later, the defect increased in size to 4.7 × 4.0
mm and 90% depth—to reach a Descemetocele—and vision decreased to 20/400. After the informed consent and discussion of possible complications he underwent DSAEK surgery for tectonic purposes.
Briefly, a donor endothelial lenticule of 72-year-old cornea with endothelial cell density of 2700
was prepared using the Moria LSK microkeratome (Moria/Microtek, Inc., Doylestown, Pennsylvania) with a 350 microns head. Immediately after that the graft was trephined with an 8.5
mm punch. The recipient was prepared with a 5
mm superior scleral tunnel incision and an anterior chamber maintainer was placed nasally. Endothelial scraping and scoring were done being careful not to perforate the already fragile cornea. The lenticule was inserted using the Busin Glide (Moria, USA) and forceps. The main wound was sutured tightly and the anterior chamber was completely filled with air for a period of 10 minutes after which a 50% residual air bubble was left.
At postoperative day 1 the lenticule was attached, the anterior chamber was formed, and intraocular pressure was normal (). Eye patch was placed and moxifloxacin 1% (Vigamoxi, Alcon laboratories, Fort Worth Texas, EU) and prednisolone acetate 1% (Prednefrin, Allergan, Los Angeles, CA, USA) were instilled QID. Lubrication with unpreserved Sodium Hyaluronate (Lagricel Sophia laboratories, Guadalajara, Mexico) was continued every hour. Pressure patch was placed and the patient was examined in the clinic every 72 hours for the next 14 days.
Figure 1 Day 1 postoperatively. (a) Slit lamp photography showing epithelial defect staining with fluorescein, mild corneal edema, and well-attached posterior lenticule. (b) Visante OCT showing epithelial defect, stromal thinning, and attachment of the posterior (more ...)
At 1 month postoperatively the graft was still well adhered, but a 4.00
mm persistent epithelial defect was present with no signs of epithelial healing. A multilayer amniotic membrane graft using cryopreserved amniotic membrane (AMNIOCV; Instituto de Oftalmologia “Conde de Valenciana” IAP, Mexico City, Mexico) was then performed and sutured with 10-0 nylon. The ocular surface healed quickly and an epithelial healing occurred over a 2-week period (). The sutures were removed and the topical medications reduced to unpreserved sodium hyaluronate (Lagricel Sophia) five to six times a day and topical and prednisolone acetate 1% (Allergan) QID and tapered over the next 4 months.
Figure 2 Month 1 postoperatively. (a) Slit lamp photography showing an integrated amniotic membrane graft, stromal thinning and adhered endothelial graft. (b) Visante OCT showing integrated amniotic membrane graft, stromal thinning, and well-attached endothelial (more ...)
Eight months after the procedure the patient had a stable and healthy ocular surface with adequate corneal integrity (). Penetrating keratoplasty to restore optical properties of the cornea and to promote visual rehabilitation is considered for the near future.
Figure 3 Month 8 postoperatively. (a) Slit lamp photography showing smooth and stable ocular surface, no epithelial defect, and mild stromal thinning. (b) Visante OCT showing a totally adhered posterior lenticule, a structurally stable cornea with a mild stromal (more ...)