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Epithelial Downgrowth Following Descemet’s-Stripping Automated Endothelial Keratoplasty

B. Michael Walker, MD; Holly B. Hindman, MD; Katayoon B. Ebrahimi, MD; W. Richard Green, MD; Charles G. Eberhart, MD, PhD; Ivan Garcia, MD; Albert S. Jun, MD, PhD
Arch Ophthalmol. 2008;126(2):278-280. doi:10.1001/archophthalmol.2007.58.
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Corneal endothelial cell dysfunction is a common indication for penetrating keratoplasty.1 Significant postoperative complications such as high astigmatism, suture breakage or infection, and graft dehiscence have led to the development of alternative surgical approaches for endothelial replacement. In 1999, Melles et al2 reported a successful case of posterior lamellar keratoplasty in a human patient. This procedure was subsequently modified and renamed deep lamellar endothelial keratoplasty in 2001 by Terry and Ousley.3 Compared with penetrating keratoplasty, advantages of deep lamellar endothelial keratoplasty include reduced postoperative astigmatism with quicker visual recovery and a lower frequency of wound dehiscence and suture complications.4,5 However, this procedure was slow to gain widespread acceptance owing in part to its technically demanding nature. Melles et al6 subsequently developed a technique called descemetorhexis for stripping Descemet's membrane from the host cornea, thereby eliminating the difficult intralamellar dissection in the recipient and allowing more surgeons to adopt this procedure, which was named Descemet's stripping with endothelial keratoplasty.7 Another advantage of Descemet's stripping with endothelial keratoplasty over deep lamellar endothelial keratoplasty is a smoother recipient corneal interface, which may reduce light scatter and improve visual acuity outcomes. A further development in the evolution of endothelial keratoplasty includes the use of an automated microkeratome to create a lamellar dissection of the donor cornea to obtain the partial-thickness, posterior donor tissue. This variation has been termed Descemet’s-stripping automated endothelial keratoplasty (DSAEK) by Gorovoy.8

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Figure 1.

Slitlamp photographs of affected cornea. A, Sclerotic scatter technique showing multiple areas of opacification within and outside (asterisk) the margins of the Descemet’s-stripping automated endothelial keratoplasty graft. B, Slit beam showing areas of opacification in the graft-host interface (black arrow) and along the posterior corneal surface (white arrow).

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Figure 2.

In vivo confocal microscopy image showing large, polygonal cells in the graft interface consistent with an epithelial cell appearance.

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Figure 3.

Histopathology of epithelial downgrowth. A, Light microscopy image of the corneal button removed 1 year after Descemet’s-stripping automated endothelial keratoplasty. A scar of perforation appears at the right tissue margin with incarceration of the stripped and folded Descemet's membrane (arrow). A cleft lined by the epithelium appears between the stroma and the folded Descemet's membrane (arrowhead) (periodic acid–Schiff, original magnification ×10). B, Higher magnification of the cleft with 2 to 3 layers of the epithelium and rare pigmented cells (arrow) as well as the folded Descemet's membrane (arrowhead) (periodic acid–Schiff, original magnification ×160). C and D, The epithelium stains positive on immunohistochemistry with anticytokeratin monoclonal antibodies AE1 and AE3 (arrow) (AE1 and AE3, original magnification ×20 [C] and ×160 [D]).

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