Moran CORE

Open source ophthalmology education for students, residents, fellows, healthcare workers, and clinicians. Produced by the Moran Eye Center in partnership with the Eccles Library

Search Moran CORE

A Case Report of Unintentional Descemet’s Stripping without Endothelial Keratoplasty (DWEK)

Title: A Case Report of Unintentional Descemet’s Stripping without Endothelial Keratoplasty (DWEK)
Author: Austin S. Nakatsuka, MD; Amy Lin, MD
Date: 12/18/2019
Keywords/Main Subjects: cornea, corneal transplant, endothelial, keratoplasty, Fuch’s dystrophy
Diagnosis: Fuch’s endothelial dystrophy
Report of Case:

A 56 year old female presented for evaluation of a visually significant posterior polar cataract and fuch’s endothelial dystrophy in the right eye. She had previously been treated with hypertonic sodium chloride ointment (Muro 128 5%, Bausch and Lomb©) four times a day with no significant improvement in clinical signs and visual acuity. After discussion, she agreed to a combined Descemet’s membrane endothelial keratoplasty (DMEK) and cataract removal with intraocular lens (IOL) procedure. The procedure was uneventful and her graft was attached and in good position on post op day 1. On post op week 1, her cornea was noted to be edematous and did not change by post op week 2.5 despite confirmation of graft attachment and orientation by anterior segment OCT (see image A and B).

On her post op month 1 visit, it was found that her graft had detached (see image C) and plans were made for a descemet’s stripping endothelial keratoplasty (DSEK).

However, at the 6 week post op visit, it was noted that the corneal edema had resolved and her vision had improved from CF to BCVA 20/40. At 2 months after the initial DMEK procedure the patient underwent DMEK graft removal only. At 2.5 years after initial DMEK procedure, the patient is currently BCVA 20/25, happy with vision, and the cornea is centrally clear without edema (image D).

D) Clear cornea at 2.5 years post-operatively after DMEK procedure (DMEK graft has been removed); the scalloped edge of the descemetorhexis is visible on slit lamp exam (not appreciated in photo) (9/30/17).

E) Specular microscopy of the right eye at 6 months post-operatively revealed a cell density of 826 cells/mm2; and moderate polymegathism (10/23/17).

Discussion:

Descemet’s stripping without endothelial keratoplasty (DWEK) or Descemet’s stripping only (DSO) is a technique described in multiple case reports and studies.1-10 The advantages of DWEK include reduced need for topical steroids (thus reducing secondary effects such as cataract formation and steroid response intraocular pressure changes), no risk of graft rejection, and theoretical decreased risk for intraocular infections related to graft implantation. Additionally, this decreases the financial burden associated with corneal grafts. DWEK has been used with significant efficacy in corneal clearing in patients with mild to moderate Fuch’s dystrophy in regards to visual outcomes, although recovery times are typically longer with an average of 5 to 11 weeks until complete visual recovery.1-5 Topical netarsudil, a Rho-associated protein kinase (ROCK) inhibitor that has shown efficacy in glaucoma but also in corneal clearing, has been used with success as an adjunctive therapy to DWEK.6-7 The rationale behind the successful cornea clearing after DWEK is that removing diseased endothelium allows healthy endothelium in the periphery to migrate to the corneal center and thus, leading to successful corneal clearing.1-3

In retrospective studies, DWEK has been done with a 4 mm descemetorhexis.1-5,8-9 In our case, the original DMEK was done with a larger 7.75 mm descemetorhexis, which likely removed more endothelial cells than is typically the case in planned DWEK procedures. Nevertheless, the time for visual recovery in our patient was comparable to patients who had undergone planned DWEK in other studies.2-9 Topical netarsudil was not used as this was not a planned DWEK case and the only post op drops used were topical ocufloxacin for 1 week and prednisolone 4 times per day for 8 weeks, with a slow taper. However, the patient has done well post-operatively, confirming that DWEK may be an efficacious option for select patients with Fuch’s endothelial dystrophy.

References:

  1. Borkar DS, Veldman P, Colby KA. Treatment of Fuchs Endothelial Dystrophy by Descemet Stripping Without Endothelial Keratoplasty. Cornea. 2016 Oct;35(10):1267-73. PubMed PMID: 27310885.
  2. Davies E, Jurkunas U, Pineda R 2nd. Predictive Factors for Corneal Clearance After Descemetorhexis Without Endothelial Keratoplasty. Cornea. 2018 Feb;37(2):137-140. PubMed PMID: 29053562.
  3. Huang MJ, Kane S, Dhaliwal DK. Descemetorhexis Without Endothelial Keratoplasty Versus DMEK for Treatment of Fuchs Endothelial Corneal Dystrophy. Cornea. 2018 Dec;37(12):1479-1483. PubMed PMID: 30222714.
  4. Koenig SB. Planned Descemetorhexis Without Endothelial Keratoplasty in Eyes With Fuchs Corneal Endothelial Dystrophy. Cornea. 2015 Sep;34(9):1149-51. PubMed PMID: 26186374.
  5. Malyugin BE, Izmaylova SB, Malyutina EA, Antonova OP, Gelyastanov AM. [Clinical and functional results of one-step phaco surgery and central descemetorhexis for cataract and Fuchs primary endothelial corneal dystrophy]. Vestn Oftalmol. 2017;133(6):16-22. PubMed PMID: 29319665.
  6. Moloney G, Petsoglou C, Ball M, Kerdraon Y, Höllhumer R, Spiteri N, Beheregaray S, Hampson J, DʼSouza M, Devasahayam RN. Descemetorhexis Without Grafting for Fuchs Endothelial Dystrophy-Supplementation With Topical Ripasudil. Cornea. 2017 Jun;36(6):642-648. PubMed PMID: 28476048.
  7. Ploysangam P, Patel SP. A Case Report Illustrating the Postoperative Course of Descemetorhexis without Endothelial Keratoplasty with Topical Netarsudil Therapy. Case Rep Ophthalmol Med. 2019;2019:6139026. eCollection 2019. PubMed PMID: 31737390; PubMed Central PMCID: PMC6815562.
  8. Shah RD, Randleman JB, Grossniklaus HE. Spontaneous corneal clearing after Descemet’s stripping without endothelial replacement. Ophthalmology. 2012 Feb;119(2):256-60. Epub 2011 Oct 7. PubMed PMID: 21982414; PubMed Central PMCID: PMC3409435.
  9. Ziaei M, Barsam A, Mearza AA. Spontaneous corneal clearance despite graft removal in Descemet stripping endothelial keratoplasty in Fuchs endothelial dystrophy. Cornea. 2013 Jul;32(7):e164-6. PubMed PMID: 23594769.
  10. Nanda GG, Alone DP. REVIEW: Current understanding of the pathogenesis of Fuchs’ endothelial corneal dystrophy. Mol Vis. 2019 Jun 5;25:295-310. PMID: 31263352; PMCID: PMC6571125.

 

Faculty approval by: Amy Lin, MD

Disclosure (Financial or other): None

Identifier: Moran_CORE_27235
Copyright statement: Copyright 2019. Please see terms of use page for more information.