Descemet Membrane Endothelial Keratoplasty in an eye with 33mm axial length

To describe the preoperative planning, intraoperative surgical techniques, and postoperative outcomes of Descemet Membrane Endothelial Keratoplasty (DMEK) in an eye with extreme axial myopia.

A 71-year-old female patient with severe 4+ nuclear sclerotic cataract and Fuchs dystrophy in the right eye presented with best corrected visual acuity of counting fingers. Central corneal thickness (CCT) was 605 microns, and optical biometry-based axial length was 33mm. The DMEK graft was preloaded as a 7.5mm diameter scroll in a micro Jones tube, injected into the anterior chamber (AC), and opened without complication.

Intraoperatively, the AC deepened and shallowed extensively, consistent with zonular laxity. Despite a large volume of SF₆, exotropia resulted in nasal displacement of the bubble and delayed attachment of the inferotemporal graft. Two subsequent 200μL air bubbles were placed in clinic with the inferotemporal graft attaching after the patient laterally positioned on her non-operative side. After 1 month, visual acuity improved to 20/500, limited by myopic degeneration, and CCT to 525 microns. By six weeks, the graft was fully attached and the cornea clear.

DMEK is feasible in eyes with extreme axial length, but presents distinct challenges such as zonular laxity and exotropia. This case underscores the importance of individualized surgical planning and positioning in achieving successful outcomes in highly myopic eyes.