An 85-year-old woman with early dementia presents with a 5-year history of decreased vision and intermittent pain in one eye. In the past, she had phacoemulsification with intraocular lenses in both eyes. The diagnosis was pseudophakic bullous keratopathy or chronic corneal edema.
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Ophthalmologist Scott Wagenberg, MD, opted to perform endothelial keratoplasty, a treatment that’s become the standard of care for treating pseudophakic corneal edema.
According to Dr. Wagenberg, this surgical technique can be performed with relative ease. It only replaces damaged endothelial cells and Descemet’s layers, maintains the integrity of the host cornea and allows for quick visual recovery compared with other approaches. “We thought that this procedure would best alleviate the patient’s pain, and so we moved ahead with surgery,” says Dr. Wagenberg.
Visual acuity was limited to light perception. A slit lamp examination found diffuse corneal edema and superficial/deep diffuse corneal neovascularization from the 2 to 10 o’clock position. In addition, it showed diffuse corneal haze/opacity and significant superficial and deep stromal corneal neovascularization from the 4 to 6 o’clock position that extended through the visual axis.
Partial limbal stem cell deficiency from the 4 to 6 o’clock position was presumed but not confirmed by cytology. No significant funduscopic abnormalities were found when compared with the other eye. The bilateral intraocular pressure was 16.
Treatment consisted of recession of the conjunctiva and Tenon’s in the area of the superficial neovascularization. Dr. Wagenberg then performed an extensive superficial keratectomy, removing the irregular epithelium and superficial corneal neovascularization. He cauterized the area at the origin of the neovascularization, i.e., at the limbus in the area of the deep feeder vessels and posterior to the limbus in the area of the superficial feeder vessels.
After that, he used the Descemet’s stripping automated endothelial keratoplasty (DSAEK) surgical technique, followed by amniotic graft reconstruction of the limbus in the area of the deep vessels. A donor disc was folded in 60-40 taco with Healon in the interface and inserted into the anterior chamber with non-contact Goosey forceps. Dr. Wagenberg made drainage incisions, and the patient wore a ProKera contact lens for seven days.
By the following day, the patient had good adherence to the donor graft. Dr. Wagenberg removed the ProKera lens after one week. Postoperative vision improved. The best spectacle corrected visual acuity was 20/100 at one month, 20/70 at two months, 20/50 at six months, 20/30 at 18 months, 20/50+ at two years, and 20/40 at three years. The superficial and deep corneal neovascularization regressed after surgery and completely disappeared by two months. No evidence of recurrence took place after surgery. The corneal haze improved, and by three years was almost completely resolved.
“We treated to eliminate corneal neovascularization and restore endothelial cell function, the epithelium and epithelial basement membrane, and corneal transparency,” says Dr. Wagenberg. This case shows that proper epithelial and endothelial function can restore corneal clarity and maintain its avascularity.