AUG 29, 2012
The authors describe in the February issue of Ophthalmology what they believe to be the first definitive report of spontaneous corneal clearing with improved visual acuity and central endothelial cell repopulation after Descemet's stripping without endothelial replacement.
Their patient was a 34-year-old woman with bilateral decreased vision secondary to corneal edema from endothelial dysfunction. Histopathologic evaluation confirmed a dual diagnosis of Fuchs' endothelial dystrophy and posterior polymorphous membrane dystrophy (PPMD).
The patient underwent an uncomplicated Descemet's stripping endothelial keratoplasty (DSEK) using a standard surgical technique in the right eye. However, primary graft failure occurred after displacement and repositioning. Repeat DSEK was performed but the donor lenticule began to progressively detach peripherally. Serial confocal microscopy demonstrated repopulation of endothelial cells specifically in the areas where the donor tissue had detached. UDVA improved to 20/80 despite the opaque donor lenticule graft being completely detached and in the anterior chamber. The donor lenticule was then removed without replacement.
Two months after this procedure, the patient's cornea had cleared and vision had significantly improved to UCVA of 20/25 and CDVA of 20/20. Confocal analysis demonstrated a complete repopulation of endothelial cells centrally.
Due to this outcome, Descemet's stripping without donor transplantation was performed in the left eye. By six months postoperatively, the left cornea cleared with a residual small area of deep stromal haze that appeared to correspond with the last region of endothelial cell repopulation. The right cornea remained clear. The patient had UCVA of 20/25 bilaterally. Confocal analysis demonstrated the same complete central repopulation of endothelial cells in the left eye.
The authors say that it is possible that the lack of donor tissue facilitated the scar formation. They hypothesize that the patient's underlying PPMD contributed to the endothelial cell's ability to centrally migrate. They say it is also possible that over time the patient's corneal clouding may return by this same mechanism. Her young age also may have facilitated endothelial cell migration.
They conclude that further study is necessary before concluding whether the results are applicable to most patients with PPMD and whether patients with PPMD ultimately will do better with standard DSEK or simple Descemet's removal.