Hasan Somar M, Jakob-Girbig Juliane, Pateronis Konstantinos, Meller Daniel
Department of Ophthalmology, Jena University Hospital, Germany.
Am J Ophthalmol Case Rep. 2021 Mar 31;22:101077. doi: 10.1016/j.ajoc.2021.101077. eCollection 2021 Jun.
to report a case of delayed Descemet membrane detachment (DMD) 45 years after penetrating keratoplasty (PK) for keratoconus and its management with a partial descemetorhexis after failed air/gas descemetopexy. A pathomechanism of DMD is proposed based on the anatomic appearance of the DMD and the success of descemetorhexis.
a 60-year old male presented with acute corneal edema of his left eye 45 years after successful PK for keratoconus. Anterior segment ocular coherence tomography (AS-OCT) revealed a wide area of DMD without a visible tear. Reattachment was tried using air and gas descemetopexy with only temporary success. A partial descemetorhexis was then performed just centrally to the graft-host interface and only in the detached area followed by injection of gas bubble. Complete reattachment of Descemet membrane (DM) on the 1st post-operative day was achieved. This anatomical success was maintained 3 months post-surgery and accompanied by decrease of central corneal thickness, however with uncomplete restoration of visual acuity.
delayed DMD following KP for keratoconus should be differentiated from acute graft rejection. It could be a result of Descemet tear, but in some cases and despite careful observation of AS-OCT no tear could be seen. In such cases, a tractional detachment of DM might be the underlying pathomechanism and descemetorhexis could help manage it. This new surgical approach might help avoid a re-keratoplasty.
This is the first case report describing success of partial descemetorhexis as a surgical management option for delayed DMD and suggesting a pathogenesis based on this success. This might help avoid re-keratoplasty as a management of this rare complication.
报告1例圆锥角膜穿透性角膜移植术（PK）45年后发生延迟性后弹力层脱离（DMD）的病例，以及在空气/气体后弹力层固定术失败后采用部分后弹力层撕除术的治疗情况。基于DMD的解剖学表现和后弹力层撕除术的成功，提出了DMD的发病机制。
1例60岁男性，在成功进行圆锥角膜PK术后45年，左眼出现急性角膜水肿。眼前节光学相干断层扫描（AS-OCT）显示大片DMD，未见明显撕裂口。尝试使用空气和气体后弹力层固定术进行复位，仅取得暂时成功。然后在移植片-宿主界面中央且仅在脱离区域进行部分后弹力层撕除术，随后注入气泡。术后第1天实现了后弹力层（DM）的完全复位。术后3个月维持了这种解剖学上的成功，同时中央角膜厚度减小，但视力未完全恢复。
圆锥角膜PK术后延迟性DMD应与急性移植排斥反应相鉴别。它可能是后弹力层撕裂的结果，但在某些情况下，尽管仔细观察AS-OCT仍未见撕裂口。在这种情况下，DM的牵引性脱离可能是潜在的发病机制，后弹力层撕除术可能有助于治疗。这种新的手术方法可能有助于避免再次角膜移植。
这是首例描述部分后弹力层撕除术作为延迟性DMD手术治疗选择取得成功并基于此成功提出发病机制的病例报告。这可能有助于避免将再次角膜移植作为这种罕见并发症的治疗方法。
