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
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).
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.
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Faculty approval by: Amy Lin, MD
Disclosure (Financial or other): None