DMEK for management of rare and complex anterior segment disease

Abstract Body:

Purpose: Very few reports have been published on the feasibility of DMEK in complex anterior segment disease. The scientific literature remains very scarce on the safety an efficacy of DMEK in rare anterior segment disease. In this case series, we report our experience and lesson learned from DMEK surgery of rare and complex anterior segment disease

Study Design: Retrospective, non-comparative, case series

Methods: Two eyes in 2 patients diagnosed with unilateral ICE syndrome (Cases 1 & 2), one eye with epithelial downgrowth following cataract surgery (Case 3) and one eye with Axenfeld-Rieger syndrome (Case 4) were treated with DMEK by 1 surgeon (J.C.) at a tertiary center (Maisonneuve-Rosemont Hospital, Montreal, QC) between December 2015 and June 2017. Patient demographics, past medical and ocular history, pre-operative assessment, surgical protocol and post-operative follow-ups were collected from chart review.

Results: All patients underwent DMEK surgery following standard protocolCase 1: BCVA improved to 20/25 from post-op 1 month. Graft was clear and there was no recurrence at last follow-up of 4 months. Case 2: BCVA improved to 20/100 on post-op day 1 and continued to improve to 20/30 at 1 year follow-up. There was no evidence of recurrence or graft failure at 1 year follow-up. Case 3: The patient underwent intra-operative Argon laser and 5-FU anterior chamber lavage before DMEK implantation. The wound was closed with cyanoacrylate glue. Post-operatively at day 2, rebubbling was required for partial graft detachment. BCVA improved to 20/60, graft was clear, the wound was Siedel negative and IOP normalized up to last follow-up at post-op 5 months.  Case 4: BCVA improved from 20/400 to 20/60 at 1 month post-operatively. Graft remained clear and attached. However patient had IOP rise due to steroid response that warranted a trabeculectomy at one month post-operatively. 

Conclusions: DMEK seems to be a safe and efficacious surgery in some eyes with rare and complex anterior disease. Careful selection of patient and proper post-operative care are crucial in guaranteeing the success of the surgery. In cases of anterior segment abnormalities, anterior chamber reconstruction should be planned through cataract extraction and/or GSL in order to make unfolding of the graft easier. In cases where anterior segment abnormalities are advanced, DSAEK and standard PKP remain very reasonable options for best visual outcomes. More reports are needed from different centers on their experience with DMEK surgery and rare anterior segment disease.