1. The Histology of Graft Adhesion in Descemet Stripping with Automated Endothelial Keratoplasty
Matthew Caldwell, Alan Proia, Francis DeCroos, and Natalie Afshari
Duke Eye Center
Authors have no financial interest.
Supported by an award from Research to Prevent Blindness

2. PURPOSE BACKGROUND OBJECTIVE
DSEK is the surgery of choice for endothelial dysfunction.
The most common complication is graft detachment.
The mechanism of graft adhesion is poorly understood.
OBJECTIVE
To describe the histologic findings of graft adhesion in DSEK 2

3. METHODS IRB approval Search of DSEK surgeries followed by PK
Clinical history reviewed
Slides cut and stained with
H&E
PAS
Colloidal Iron

4. Eyes with PK following DSEK
RESULTS
Eyes with PK following DSEK
Age
Sex/Race
History
Duration 1 88
F/W
Fuchs,PCIOL, DSEK
458 2 79
M/W
PCIOL,PK, DSEK
103 3 81
PCIOL, tube x2, PK x2, DSEK
232 4 90
ACIOL, DSEK
573 5 87
Tube x3, hypotony, ACIOL, DSEK
138 6 56
M/B
Tube x2, CPC, PCIOL, DSEK
373 7 23
Peters, glaucoma surg x3, PK, DSEK x2 75 8 53
Fuchs, PK, PCIOL, DSEK 9 59
F/I
PCIOL, PK, tube, synechiolysis, DSEK
490 10 64
511 }
Pseudophakic=10 (ACIOL=2)
All high risk patients with multiple ocular comorbidities
Glaucoma w/ tube = 5
Failed graft prior to DSEK = 6

5. Interface Findings
The interface was barely perceptible in most cases. Keratocyte density was unaltered at the interface.
In 3 cases, increased cellularity was noted along the unopposed stromal edge in areas of detachment.

6. Interface Material
Pigment granules and debris were seen in the interface to some extent in nearly all cases. The presence of glycosaminoglycans was not demonstrated with colloidal iron stain. 6

7. Interface Descemet Membrane
Descemet membrane was present in the peripheral interface in 8 of 10 cases.

8. Interface Descemet Membrane
Of the 10 specimens, 4 were completely attached grossly, 3 were partially separated, and 3 were completely separated. Interface Descemet membrane (DM) was noted in all three groups. In all groups the interface DM was preferentially adherent to the graft rather than the posterior stroma.
Completely
Attached
(4/10)
+DM in 4/4
More adherent to graft at split edges
Partially
Separated
(3/10)
+DM in 2/3
More adherent to graft in 1, free floating in the other
Completely
Separated
(3/10)
+DM in 2/3
Adherent only to graft in both

9. Peripheral Splitting Artifact
Peripheral splitting was present at at least one edge of all attached cases. This is presumed artifact due to shearing forces from specimen sectioning. This was present independent of the presence of Descemet membrane.
Peripheral splitting artifact. Note preferential adhesion of Descemet membrane to the graft.

10. Other Findings
Other anterior and posterior findings unrelated to the interface were present in many cases.
Fibrocollagenous pannus
Anterior stromal scarring
Paucity of endothelial cells
Retrocorneal membrane
Retrocorneal membrane

11. CONCLUSIONS
DSEK grafts form adhesion without scarring or keratocyte proliferation.
Pigment granules and Descemet membrane are common in the interface.
DSEK grafts form a firm attachment to Descemet membrane (relative to the adhesion of DM to the native posterior stroma)
Stripping of Descemet’s membrane may be unnecessary for graft adhesion