Case Report of Severe Haze After DSAEK Neil B. Griffin, MD1, Colleen C. Grace, MD2, and Sarah E. Griffin   1,2Carolina Eye Associates, P.A.   Authors have no financial interest in the subject matter of this poster.

Purpose To report a case of severe interface haze caused by an irregular donor stromal surface following Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)   Neil Griffin, MD

Introduction Endothelial keratoplasty (EK) has become the predominant surgical treatment for corneal endothelial failure in the United States.1 Unsatisfactory vision resulting from wrinkles or folds in the graft has been reported as the main reason for secondary graft failure and repeat endothelial keratoplasty (REK) after DSAEK2. Interface deposits have been reported after DSAEK3. Interface haze and unsatisfactory vision in this case was secondary to an irregular donor cornea surface. Neil Griffin, MD

DSAEK Surgical technique Temporal 4mm limbal three plane incision. Phacoemulsification and posterior chamber lens implantation Descemet’s stripped under BSS irrigation Precut donor tissue (Moria CB) provided by Ocular Systems, Inc. (OSI) Donor graft insertion device, Endosaver™, under an IRB study. Currently FDA approved as Endoserter™ Air compression technique Full anterior chamber air fill IOP of 30-50 mm for 10 minutes BSS air fluid exchange, <50% chamber air, IOP 30 mm. Neil Griffin, MD

50 yo female Fuchs’ dystrophy and cataract Right eye surgery Combined DSAEK and cataract surgery. Five months post-op, very satisfied with vision UCVA 20/40, BCVA 20/30 , + 1.00 sphere. Left eye surgery Immediate severe interface opacity Six weeks post-op Cloudy vision in the left eye only No improvement in severe haze UCVA 20/80, BCVA 20/80 Left eye Re-graft Severe interface haze eliminated, Very satisfied with vision UCVA 20/40 at 5 weeks Fuzzy donor Re-graft Neil Griffin, MD

The Fuzzy Donor Microscopic inspection of the explanted donor in solution revealed a frayed, fuzzy donor surface Donor information 48 yo, 2900 ECC Preservation Interval 8 hrs, 30 min Abnormal surface not noted at processing Graft thickness 124 microns Processing to surgery time: 15 hours Death to surgery time: 84 hours Mate cornea: successful DSAEK without haze Neil Griffin, MD

Discussion Our first graft failure secondary to interface haze in over 600 DSAEK procedures Haze created by the ragged, frayed surface has characteristic appearance at slit lamp. OSI: 3 reported cases of “wispy” interface opacity in over 8,500 processed EK grafts Neil Griffin, MD

Irregular Donor Surface Interface Haze Small percentage of DSAEK patients have irregular donor surface haze Haze may be focal (photo) Many patients with central haze are satisfied with visual outcome and do not require re-graft. Neil Griffin, MD

Progression of surface irregularity ? A second severely irregular donor graft was detected after extended storage. (photo, video) Donor graft 20 yo, 3079 ECC Preservation Interval 9 hrs,8min Abnormal surface not noted at processing Graft thickness 157 microns Processing to surgery time: 70.5 hours Delay due to scheduled case cancellation and relocation of donor tissue. Death to surgery time: 168 hours Tissue was mounted on chamber for pre-op inspection because of extended storage time. Tissue found not suitable for transplant. Mate cornea: successful DSAEK without haze Neil Griffin, MD

Lamellar Dissection in the Posterior Stroma This case was our first encounter with an irregular surface following dissection with a microkeratome. The donor graft surface was similar to our previous unpublished laboratory studies of femtosecond laser lamellar dissections in the posterior stroma. (photo) We have not observed the irregular surface with dissections in the anterior stroma Cornea ultrastructure studies may help explain why this phenomenon appears to be confined to dissections in the posterior stroma4. Neil Griffin, MD

Conclusion Severe interface haze after DSAEK can be the result of an irregular donor stromal surface. Re-grafting can improve visual outcome in these cases. Etiology of the irregular lamellar donor surface is unknown. 1 Neil Griffin, MD

References 1. Eye Bank Association of America. 2009 Eye Banking Statistical Report. Washington, DC: Eye Bank Association of America; 2010:14-5. 2. Letko E, Price DA, Lindoso E MS, Price MO, Price FW Jr. Secondary Graft Failure and Repeat Endothelial Keratoplasty after Descemet’s Stripping Automated Endothelial Keratoplasty. Ophthalmology 2011;118:310-314. 3. KymionisGD, Ide T, Yoo SH. Interface Wavelike Deposits After Descemet Stripping Automated Endothelial Keratoplasty. J ARCH OPHTHALMOL/VOL 127 (NO. 10), OCT 2009. 4.Jester JV, Winkler M, Jester BE, Nien C, Chai D, Brown DJ, Eye Contact Lens. 2010 Sep;36(5):260-4. Neil Griffin, MD