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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01038-1
10.1016/j.ijscr.2024.110257
110257
Case Report
Utilization of Ophthalmic Technology and Advances in Endothelial Keratoplasty: A Case Report
Babaker Raghad ab
Alruwaili Rahaf ac
Khan Saud Abdulbadie ad
Fairaq Rafah a
AlMutlak Mohammed a
Bin Helayel Halah hbinhelayel@kkesh.med.sa
a⁎
a Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
b Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
c Department of Ophthalmology, King Abdulaziz Specialist Hospital, Al Jouf, Saudi Arabia
d Department of Ophthalmology, Ohud Hospital, Madinah, Saudi Arabia
⁎ Corresponding author. hbinhelayel@kkesh.med.sa
07 9 2024
10 2024
07 9 2024
123 11025724 6 2024
30 8 2024
5 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

The authors report a case of a 65-year-old male with corneal decompensation associated with poor vision with a recent history of cataract surgery.

Case presentation

A patient presented with complaints of poor vision in the left eye. The patient had undergone phacoemulsification surgery 4 months prior to presentation. The presenting best corrected vision was 20/400 in the left eye with the presence of corneal edema and central Descemet's membrane detachment (DMD) extending to the inferior two-thirds of the cornea with a fibrotic demarcation line separating detached Descemet's from intact, attached Descemet's.

Clinical discussion

Anterior segment optical coherence tomography (AS-OCT) confirmed the diagnosis of Type 1 DMD. The patient was managed with femtosecond laser-assisted descematorrhexis with intraoperative AS-OCT, and a ready preloaded Descemet stripping endothelial keratoplasty graft.

Conclusions

This report emphasizes that many technological advancements in the field can be employed to improve the outcomes of endothelial keratoplasty, especially when fibrosis is associated with the combined PDL and DMD.

Highlights

• Many technological advancements can be employed to improve endothelial keratoplasty outcomes, such as FS laser and AS-OCT.

Keywords

Corneal decompensation
Femtosecond laser
Ophthalmology
Endothelial keratoplasty
Cataract surgery complications
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pmc1 Introduction

Descemet's membrane detachment (DMD) is characterized by a tear in the Descemet's membrane (DM), which can occur spontaneously or iatrogenically during intraocular surgeries. The reported incidence of DMD during extracapsular cataract surgery is approximately 2%–6%and during phacoemulsification cataract surgery is around 0%–5% [1].

In recent years, advancements in technology have revolutionized the field of ophthalmology, offering new tools and techniques to enhance surgical outcomes and mitigate complications. One such technological advancement is anterior segment optical coherence tomography (AS-OCT). AS-OCT provides non-invasive, high-resolution cross-sectional images of the anterior eye segment, enabling precise visualization of ocular structures. Its emergence as a valuable tool has transformed our understanding of corneal tissue behavior during various procedures, including anterior and posterior lamellar corneal transplant surgery. Additionally, AS-OCT has paved the way for innovative surgical techniques, such as pre-Descemet's endothelial keratoplasty, suture management for acute hydrops, deep anterior lamellar keratoplasty-triple (DALK-triple), and Fogla's mini DALK [2].

In this context, we present a compelling case study involving a patient who experienced corneal decompensation and poor vision following cataract surgery. We present a unique approach to addressing DMD using ophthalmic technology. Our focus lies on the application of femtosecond laser technology during endothelial keratoplasty. By emphasizing the role of this innovative tool, we aim to shed light on its impact on managing DMD and improving patient outcomes. We also employed AS-OCT to visualize the DMD precisely and guide our surgical interventions. Furthermore, pre-stripped, pre-cut, and preloaded endothelial tissue grafts were utilized for Descemet's stripping automated endothelial keratoplasty (DSAEK). By combining these innovative approaches, we achieved successful outcomes for our patient. This case report provides valuable insights into the intersection of technology and ophthalmology, offering a glimpse into the future of precision surgical interventions. The outcomes of this paper are important to ophthalmic surgeons and the wider field of ophthalmology. By understanding the incidence and identifying the correct type of DMD using anterior segment OCT, we can optimize surgical outcomes, enhance patient safety, establish evidence-based guidelines for management, minimize complications, and reduce surgical time and surgeon stress. This work has been reported in line with the SCARE criteria [3].

2 Case presentation

A 65-year-old male patient was referred to our hospital with complaints of decreased vision after undergoing phacoemulsification surgery in his left eye four months prior to presentation. At presentation, the patient's uncorrected visual acuity in the left eye was 20/400 with intraocular pressure within normal limits. Slit lamp examination at presentation revealed corneal edema with a central detachment of Descemet's membrane (DMD) extending to the lower two-thirds of the left cornea (Fig. 1). A fibrotic demarcation line was observed, separating the detached portion of Descemet's membrane from the intact, attached portion. The diagnosis of Type 1 DMD, as described by Dua et al., was confirmed using AS-OCT (MS-39 AS-OCT; CSO, Florence, Italy) [2]. The AS-OCT images showed a separation between the pre-Descemetic layer [PDL or Dua's Layer (DL)] and DM from the overlying stroma. The detached membrane appeared relatively thicker, taut, hyperreflective, and straight, resembling a circle chord (Fig. 2).Fig. 1 Slit lamp photo showing moderate diffuse corneal edema, more pronounced in the inferior two-thirds of the cornea, related to the central Descemet's membrane detachment.

Fig. 1

Fig. 2 Anterior segment optical coherence tomography image showing a separation between the pre-Descemetic layer (PDL) and Descemet's membrane from the overlying stroma, Type 1 DMD.

Fig. 2

Considering the challenges of manual approaches and emerging literature supporting laser-assisted descematorrhexis, our choice enhances surgical outcomes and patient safety. The patient was scheduled for DSAEK and femtosecond laser-assisted descematorrhexis with the LenSx® laser (Alcon Vision LLC., Fort Worth, TX, USA). The capsulotomy in cataract surgery parameters were used, and further adjustment was made to include most of the detached area. The laser was programmed to create a cylindrical pattern with a height of 300 μm below and 100 μm above DM and a diameter of 7.8 mm. The surgeon accurately positioned the laser pattern onto the patient's nondilated pupil and initiated the descematorrhexis procedure. Subsequently, a clear corneal incision was made to access the anterior chamber and remove the DM. Any remaining tags in the fibrotic area were cut easily using a reversed Sinsky. The preloaded tissue was introduced into the anterior chamber using a glass injector. Once the graft was unfolded, the anterior chamber was filled with 90 % air under the lenticule and kept pressurized for 10 min; then, air-fluid exchange was performed. The air was kept at approximately 80 % of the anterior chamber volume. The intraoperative OCT was used to ensure proper visualization and confirmation of graft attachment. The procedure was concluded by administering subconjunctival injections of Dexamethasone and Cefazolin. The host's DM was then sent for histopathology, and the report indicated severely attenuated endothelium with pigmented retrocorneal fibrous membrane (Fig. 3A, B).Fig. 3 A, B. Both histology images show severely attenuated endothelium and pigmented retrocorneal fibrotic membrane, stained with hematoxylin and eosin stain and Periodic Acid Schiff (PAS) stain, respectively.

Fig. 3

Postoperative care involved prescribing topical steroids, antibiotics, and lubricant eye drops. On the first postoperative day, the patient underwent a comprehensive examination, including measurement of uncorrected Snellen visual acuity and slit-lamp examination. He was discharged home in stable condition. During the next few weeks, the epithelium was still thick and easily peeled off; therefore, superficial keratectomy was performed, and an Omnigen bandage contact lens (OmniLenz®, NuVision Biotherapies Ltd., Nottingham, UK) was placed over the cornea for 3 weeks to enhance further healing. Following surgery, the patient's uncorrected visual acuity (UCVA) improved to 20/160 initially, and through the subsequent visits, his UCVA further improved to 20/80, reaching 20/50 with refraction. The patient expressed satisfaction with the surgical results and the significant improvement in his vision (Fig. 4, Fig. 5).Fig. 4 Anterior segment optical coherence tomography image post-DSAEK and femtosecond laser-assisted descematorrhexis showing mild edema and 360 attached lenticule of the left eye.

Fig. 4

Fig. 5 Slit lamp photo post-DSAEK, femtosecond laser-assisted descematorrhexis, and superficial keratectomy showing mild edema centrally with no Descemet folds and attached lenticule.

Fig. 5

3 Discussion

DMD is a serious complication that leads to corneal decompensation. It is considered a less common cause of edema after cataract surgery [4]. DMD can impair corneal endothelial function, leading to corneal edema and compromised visual acuity [5]. In our study, femtosecond laser technology was pivotal in addressing DMD during endothelial keratoplasty. The laser allowed precise and controlled descematorrhexis, reducing complications such as radial tears. Intraoperative optical coherence tomography (OCT) provided real-time feedback, ensuring graft alignment and minimizing risks. Additionally, preloaded tissue reduced surgical time. Postoperatively, superficial keratectomy and using the Omnigen bandage contact lens facilitated corneal healing and improved visual outcomes.

In a recent review, Dua and his team described a new categorization of DMD based on AS-OCT. [2] In our case, the DMD can be described as Type 1 DMD, which involves the detachment of both PDL/DL and DM from the posterior stroma and usually appears as a hyper-reflective straight line. The fibrous tissue that was observed during slit lamp examination that AS-OCT can also visualize was hypothesized to result from keratocyte migration into the detached PDL/DL, where they transform into myofibroblasts/fibroblasts, leading to scarring and contracture. The other two types described by Dua and colleagues were type 2 DMD, which only involves the detachment of DM from the posterior surface of PDL/DL [2]. Type 2 DMD appears as a thin, undulating, double-contour hyper-reflective line. The last type is a mixed form where both PDL/DL and DM detach from the posterior cornea and from each other (type 3 DMD) [2]. The presence or absence of tears in DM and/or PDL/DL determines whether DMD is classified as rhegmatogenous (with tears) or non-rhegmatogenous (without tears).

Femtosecond laser technology has been a beneficial addition to the field of ophthalmology. The femtosecond laser is utilized more often in cataract surgery, where it has increased the reliability and repeatability of creating corneal wounds and anterior capsulotomies [6,7]. When combined with optical coherence tomography imaging during surgery, this laser can create highly accurate surgical incisions without affecting the surrounding tissues. This technological innovation ensures precise and controlled surgical procedures [7]. The current literature on utilizing femtosecond laser-assisted descematorrhexis in endothelial keratoplasty is limited. However, emerging literature suggests that this approach is safer and yields more precise cutting of the donor tissue [8].

Descematorrhexis is a crucial step in endothelial keratoplasty. Using a femtosecond laser for descematorrhexis can result in high-quality and accurate cutting, reducing complications such as radial tears [8]. Also, we believe that the controlled removal of DM using a femtosecond laser might result in reduced movement of the iris diaphragm, therefore minimizing the risk of hyphema, fibrin release, and cystoid macular edema (CME). Additionally, cutting DM using a femtosecond laser would decrease injury to the corneal stroma, thereby enhancing the attachment of the lenticule.

In this study, the selection of femtosecond laser technology was based on the rationale that the manual approach in addressing this particular type of detachment may present challenges and complexities during the surgery. Additionally, intraoperative OCT was a valuable tool in assessing whether there were remaining tags and ensuring graft alignment by providing immediate feedback, thereby minimizing the risk of complications, ensuring improved surgical outcomes, and enhancing postoperative visual acuity [9,10]. Furthermore, preloaded tissue was utilized in this case to reduce surgical time and stress related to tissue cutting.

Postoperative persistent epithelial thickening following DSAEK was attributed to chronic detachment and edema. Superficial keratectomy was performed to promote corneal healing and improve visual outcome. Also, the Omnigen bandage contact lens, a regenerative therapy lens utilizing an amniotic membrane derived from the placenta, was used. This approach aimed to facilitate the regeneration of healthy ocular surface tissues and create an optimal environment for corneal epithelialization, leading to improved visual outcomes and enhanced patient comfort.

Moreover, computational modeling and simulation have revolutionized biomedical research in ophthalmology. These cost-effective alternatives to traditional experiments allow us to explore complex biological processes virtually. Specifically, in DMD, we optimize descematorrhexis using computational simulations. By modeling biomechanics, we minimize complications during surgery. Additionally, in silico methods predict graft alignment, personalize treatment strategies, optimize drug delivery, and serve as educational tools for surgeons. Integrating these approaches into clinical practice enhances patient care and surgical precision [[11], [12], [13]]. We recommend advancing computational modeling in future studies by incorporating patient-specific data and multi-scale approaches. These models can enhance our understanding of corneal biomechanics, predict treatment outcomes, and guide personalized interventions. Additionally, validating computational simulations against clinical data and collaborating closely with clinicians will bridge the gap between theoretical research and practical applications, ensuring that in silico approaches become integral tools for precision ophthalmic care.

4 Conclusion

This case report highlights the successful management of DMD following phacoemulsification surgery using innovative techniques, including femtosecond laser-assisted descematorrhexis and preloaded Descemet stripping endothelial keratoplasty graft. It emphasizes that many technological advancements in the field can be exploited to improve the outcome of endothelial keratoplasty, particularly in cases involving fibrosis associated with combined PDL and DMD. These techniques offer promising outcomes for treating this rare complication, leading to significant visual improvement and patient satisfaction. Further research and studies are warranted to explore the utility of these approaches and long-term outcomes.

Funding

No funding or grant support was received for this work.

Patient consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Authorship

All authors attest that they meet the current ICMJE criteria for Authorship.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

None.
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