September 2019


Can two DSAEK grafts create a clear cornea?

by Stefanie Petrou Binder, MD EyeWorld Contributing Writer

Pentacam (Oculus) images of patient with two corneal grafts

Slit lamp image showing superimposed corneal grafts
Source (all): Ioannis Mallias, MD


It’s an unusual case study and one that occurred by mistake. Ioannis Mallias, MD, described the unexpected clinical picture and management of a patient who had a clear cornea after two simultaneous corneal grafts, placed after two separate DSAEK surgeries.
The 28-year-old male patient with congenital glaucoma presented at Dr. Mallias’ clinic with two DSAEK grafts and a clear cornea. The patient was monocular, with BCVA 20/400 in his right eye, an ocular prosthesis in his left, and three antiglaucoma valve procedures dating back over many years.
After cataract surgery, the patient developed pseudophakic bullous keratopathy with chronic corneal edema. This corneal disease is characterized by corneal stromal edema with epithelial and subepithelial bullae, caused by cell loss and endothelial decompensation through trauma from cataract surgery. It affects 1–2% of cataract surgeries and is caused by heat-related phaco damage and oxidative stress, prolonged phaco, damage from turbulent flow from high irrigation/aspiration rates, and is associated with Fuchs’ dystrophy, certain types of glaucoma, and surgeries that can cause trauma and lead to endothelial cell loss, among other etiologies.
Corneal transplantation is the gold standard for the treatment of bullous keratopathy, allowing relief of symptoms, such as pain and tearing, and visual acuity recovery. The corneal graft success rate is high, however, there is also a risk of rejection.
This patient’s history revealed that he underwent endothelial keratoplasty twice. After the first of these corneal surgeries, the surgeon placed four cardinal sutures in the cornea, which when removed had left scars on the cornea. The first graft remained clear for 2 years until the recurrence of corneal edema, which led to graft failure, necessitating a new corneal transplantation.
The second surgery was carried out by a different surgeon, who mistook the scars on the cornea from the preplaced cardinal sutures as resulting from a full thickness, penetrating keratoplasty (PK), when in fact the patient had undergone DSAEK. The miscommunication of the patient’s clinical history and failure to identify DSAEK led to an error involving a second graft transplantation on top of the first one, instead of the removal of the failed initial DSAEK graft.
“Interestingly, when the patient came to us, the cornea was clear,” Dr. Mallias said. “The first DSAEK graft was uncompromised for 2 years, then failed and should have been removed before another graft was transplanted. Because the next surgeon thought that the first corneal transplant was a full thickness graft, for this reason he did not remove the previously failed corneal graft, but added a second one instead. Surprisingly, the cornea was clear, despite chronic edema, with a corneal thickness of 974 µm. Slit lamp images distinctly showed the borders of the first and second grafts. OCT images revealed the two DSAEK grafts very clearly, one on top of the other, as well as the host cornea. We could see the attachment of both grafts to the host cornea with a little bit of edema within the cornea in one area.”
Glaucoma and corneal swelling that are associated with cataract surgery have both been noted to increase a patient’s chances of corneal graft rejection. In addition, graft rejection rates can increase with the number of corneal transplants an individual has received. Despite the patient’s complicated ocular history, with a number of conditions putting him at a greater risk of corneal failure, such as corneal scarring, chronic corneal edema, graft rejection from a previous transplant, cataract surgery complications, and two overlapping transplants, his cornea remained clear and the second graft was uncompromised.
“The cornea was not cloudy despite the fact that the two DSAEK grafts were stuck on top of one another. This unusual case shows that the cornea can remain clear despite the fact that the corneal thickness was more than 970 µm. The take-home message is that when we practice medicine, we have to be very careful and use proper diagnostics. Surgeons need to identify such cases and differentiate an eye
with PKP and one with a DSAEK in order to make the right choices for the patient,” Dr. Mallias said.

About the doctor

Ioannis Mallias, MD

Director of Laser Plus
Eye Institute
Athens, Greece

Relevant financial interests

: None

Contact information


Can two DSAEK grafts create a clear cornea? Can two DSAEK grafts create a clear cornea?
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