Primary graft failure after Descemet-stripping automated endothelial keratoplasty: clinico-pathological study

Descemet-stripping automated endothelial keratoplasty (DSAEK) is a selective tissue corneal transplantation procedure in which only the diseased endothelium and the Descemet membrane is replaced. Refractive and visual results have been encouraging with this procedure, but higher rates of primary graft failure have been noted. We herein report histopathologic and ultrastructural changes in 2 cases of primary graft failure after DSAEK. We are not aware of these features being reported previously.

Two cases of primary graft failure after DSAEK. One patient underwent DSAEK for Fuchs endothelial dystrophy and the other for pseudophakic bullous keratopathy. Both DSAEK procedures were uneventful. Postoperatively, there was no graft dislocation, but 1 patient had a nasal Descemet detachment that was reapposed with intracameral air. One month postoperatively, there was no improvement in the vision, and both patients had pronounced swelling of the recipient and donor corneas. Both patients underwent graft exchange. Both the recipient and donor corneal edema resolved.

Histopathologic evaluation showed marked corneal edema and loss of endothelial cells. Ultrastructural evaluation showed only remnant endothelial cell membranes present in 1 sample devoid of any intracellular contents. Transmission electron microscopy showed the presence of extensively damaged keratocytes in the deep posterior stroma and also in the interface at the graft-host junction.

These cases show widespread and irrecoverable endothelial and keratocyte damage in patients with primary graft failure after DSAEK.