Immunologic perspective on the denuded stromal “gutter” after Descemet membrane endothelial keratoplasty Ebru Cömert, MD, Christopher S. Sáles, MD, MPH,

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Immunologic perspective on the denuded stromal “gutter” after Descemet membrane endothelial keratoplasty Ebru Cömert, MD, Christopher S. Sáles, MD, MPH, Zachary M. Mayko, MS, Mark A. Terry, MD, Michael D. Straiko, MD JCRS Online Case Reports Volume 3, Issue 4, Pages 75-77 (October 2015) DOI: 10.1016/j.jcro.2015.08.001 Copyright © 2015 ASCRS and ESCRS Terms and Conditions

Figure 1 Descemet membrane endothelial keratoplasty graft (light blue circle) centered within an overstripped recipient stromal bed (yellow dashed line), resulting in an intervening naked gutter between the recipient Descemet membrane/endothelium and the donor DMEK graft. It is not clear whether endothelial cells migrate from the donor DMEK graft or from the recipient to fill this gap after surgery. JCRS Online Case Reports 2015 3, 75-77DOI: (10.1016/j.jcro.2015.08.001) Copyright © 2015 ASCRS and ESCRS Terms and Conditions

Figure 2 Mild rejection episode 21 months after DMEK surgery, with no limbal vessel engorgement, no stromal edema, and only a scant accumulation of keratic precipitates. JCRS Online Case Reports 2015 3, 75-77DOI: (10.1016/j.jcro.2015.08.001) Copyright © 2015 ASCRS and ESCRS Terms and Conditions

Figure 3 High magnification of 3 keratic precipitates (red square) on the gutter between the DMEK graft (smooth curved line on the left, green arrows) and the recipient Descemet membrane/endothelium (jagged line on the right, blue arrows). Note that there are keratic precipitates on the DMEK donor endothelium as well as on the gutter but none on the recipient Descemet membrane/endothelium, suggesting that the gutter has been repopulated with donor endothelium. JCRS Online Case Reports 2015 3, 75-77DOI: (10.1016/j.jcro.2015.08.001) Copyright © 2015 ASCRS and ESCRS Terms and Conditions