Deep Anterior Lamellar Keratoplasty on a Descemet's Membrane Endothelial Keratoplasty Graft: A Case Report

Deep anterior lamellar keratoplasty (DALK) has been reported in eyes following Descemet's stripping automated endothelial keratoplasty (DSAEK); however, its application after Descemet's membrane endothelial keratoplasty (DMEK) has not been reported.

The patient was an 87-year-old woman who underwent repeat DMEK for late DMEK graft failure that had healed with corneal haze due to long-term endothelial dysfunction. DALK was then performed to remove opacity and improve corneal irregular astigmatism. The corneal epithelium and stroma were removed via manual dissection to the pre-Descemet's layer. Candida parapsilosis was detected in a culture test of the obtained host corneal specimen. Because a fungal infection was detected, 0.1% voriconazole eye drops were administered in addition to antibiotic eye drops. Corneal clarity improved, but optical coherence tomography revealed cystoid macular edema (CME). Subtenon triamcinolone acetonide (STTA) injection was performed. The CME resolved 1 week after STTA injection, and the best corrected visual acuity was 0.5 (decimal) 1 month after STTA injection.

This case demonstrates that DALK can be safely performed after DMEK to treat stromal opacity and irregular astigmatism, with favorable visual and anatomical outcomes. Therapeutic DALK and prophylactic antifungal eye drops effectively treated the fungal infection and recurrence was not observed. This case highlights the clinical feasibility of staged keratoplasty and suggests that DALK may be considered a viable option for managing stromal opacity even after endothelial keratoplasty. These findings may contribute to expanding the surgical indications of DALK in complex corneal cases following endothelial keratoplasty.