Download Case Report of Severe Haze After DSAEK Neil B. Griffin, MD 1

Case Report of
Severe Haze After DSAEK
Neil B. Griffin, MD1, Colleen C. Grace, MD2, and Sarah E. Griffin
1,2Carolina
Eye Associates, P.A.
Authors have no financial interest in the subject matter of this poster.
Purpose
 To report a case of
severe interface haze
caused by an
irregular donor
stromal surface
following Descemet’s
Stripping Automated
Endothelial
Keratoplasty (DSAEK)
Neil Griffin, MD
Introduction
 Endothelial keratoplasty (EK) has become the predominant
surgical treatment for corneal endothelial failure in the United
States.1
 Unsatisfactory vision resulting from wrinkles or folds in the
graft has been reported as the main reason for secondary
graft failure and repeat endothelial keratoplasty (REK) after
DSAEK2.
 Interface deposits have been reported after DSAEK3.
 Interface haze and unsatisfactory vision in this case was
secondary to an irregular donor cornea surface.
Neil Griffin, MD
DSAEK Surgical technique
 Temporal 4mm limbal three plane incision.
 Phacoemulsification and posterior chamber lens implantation
 Descemet’s stripped under BSS irrigation
 Precut donor tissue (Moria CB) provided by Ocular Systems,
Inc. (OSI)
 Donor graft insertion device, Endosaver™, under an IRB study.
Currently FDA approved as Endoserter™
 Air compression technique
 Full anterior chamber air fill
 IOP of 30-50 mm for 10 minutes
 BSS air fluid exchange,
 <50% chamber air, IOP 30 mm.
Neil Griffin, MD
50 yo female
Fuchs’ dystrophy and cataract
 Right eye surgery
 Combined DSAEK and cataract surgery.
 Five months post-op, very satisfied with vision
 UCVA 20/40, BCVA 20/30 , + 1.00 sphere.
 Left eye surgery
 Combined DSAEK and cataract surgery.
 Immediate severe interface opacity
 Six weeks post-op
• Cloudy vision in the left eye only
• No improvement in severe haze
• UCVA 20/80, BCVA 20/80
Fuzzy donor
 Left eye Re-graft
 Severe interface haze eliminated,
• Very satisfied with vision
• UCVA 20/40 at 5 weeks
Neil Griffin, MD
Re-graft
The Fuzzy Donor
 Microscopic inspection of the
explanted donor in solution revealed
a frayed, fuzzy donor surface
 Donor information
 48 yo, 2900 ECC
 Preservation Interval 8 hrs, 30 min
 Abnormal surface not noted at processing
 Graft thickness 124 microns
 Processing to surgery time: 15 hours
 Death to surgery time: 84 hours
 Mate cornea: successful DSAEK
without haze
Neil Griffin, MD
Discussion
 Our first graft failure secondary
to interface haze in over 600
DSAEK procedures
 Haze created by the ragged,
frayed surface has
characteristic appearance at slit
lamp.
 OSI: 3 reported cases of “wispy”
interface opacity in over 8,500
processed EK grafts
Neil Griffin, MD
Irregular Donor Surface Interface Haze
 Small percentage of DSAEK
patients have irregular
donor surface haze
 Haze may be focal (photo)
 Many patients with central
haze are satisfied with
visual outcome and do not
require re-graft.
Neil Griffin, MD
Progression of surface irregularity ?
 A second severely irregular donor graft
was detected after extended storage.
(photo, video)
 Donor graft






20 yo, 3079 ECC
Preservation Interval 9 hrs,8min
Abnormal surface not noted at processing
Graft thickness 157 microns
Processing to surgery time: 70.5 hours
• Delay due to scheduled case cancellation
and relocation of donor tissue.
Death to surgery time: 168 hours
 Tissue was mounted on chamber for pre-
op inspection because of extended
storage time.
 Tissue found not suitable for transplant.
 Mate cornea: successful DSAEK without
haze
Neil Griffin, MD
Lamellar Dissection in the Posterior Stroma
 This case was our first encounter
with an irregular surface following
dissection with a microkeratome.
 The donor graft surface was similar
to our previous unpublished
laboratory studies of femtosecond
laser lamellar dissections in the
posterior stroma. (photo)
 We have not observed the irregular
surface with dissections in the
anterior stroma
 Cornea ultrastructure studies may
help explain why this phenomenon
appears to be confined to
dissections in the posterior
stroma4.
Neil Griffin, MD
Conclusion
 Severe interface haze after
DSAEK can be the result
of an irregular donor
stromal surface.
 Re-grafting can improve
visual outcome in these
cases.
 Etiology of the irregular
lamellar donor surface is
unknown.
Neil Griffin, MD
1
References
1. Eye Bank Association of America. 2009 Eye Banking
Statistical Report. Washington, DC: Eye Bank
Association of America; 2010:14-5.
2. Letko E, Price DA, Lindoso E MS, Price MO, Price FW
Jr. Secondary Graft Failure and Repeat Endothelial
Keratoplasty after Descemet’s Stripping Automated
Endothelial Keratoplasty. Ophthalmology 2011;118:310-314.
3. KymionisGD, Ide T, Yoo SH. Interface Wavelike Deposits
After Descemet Stripping Automated Endothelial Keratoplasty.
J ARCH OPHTHALMOL/VOL 127 (NO. 10), OCT 2009.
4.Jester JV, Winkler M, Jester BE, Nien C, Chai D, Brown DJ, Eye Contact
Lens. 2010 Sep;36(5):260-4.
Neil Griffin, MD