Descemet stripping endothelial keratoplasty (DSEK) has gained immense popularity in the past few years among corneal surgeons as the technique of choice for selective endothelial transplantation.1 A recent report by the American Academy of Ophthalmology described DSEK as an effective treatment for endothelial disease, similar to penetrating keratoplasty in terms of surgical risks and complication rates.2 Although the available evidence enlists graft dislocation, endothelial rejection, graft failure, and glaucoma as the four most common complications of DSEK,2,3 a reliable estimate of the incidence and ranking of complications associated with DSEK remains to be determined because of its recent adoption as a surgical alternative to full-thickness corneal transplantation. There have been isolated reports of occurrence of hemorrhage between the donor and host corneal interface after DSEK surgery. Suh et al. had one case out of 118 with interface blood that resolved spontaneously.3 We recently encountered a case with extensive and recurrent interface blood after DSEK in a patient using systemic anticoagulants. The hemorrhage did not respond to repeated washout of the donor-graft interface.
An 84-year-old Chinese woman underwent DSEK in her left eye for pseudophakic bullous keratopathy. Preoperative best-corrected visual acuity (BCVA) was 20/30 OD and 14/200 OS. Intraocular pressure (IOP) was 18 and 13 mm Hg in the right and left eyes, respectively. Right eye examination revealed a clear cornea with intraocular lens in situ. Posterior segment examination was unremarkable bilaterally. Previous medical history revealed the presence of ischemic heart disease and history of coronary angioplasty, requiring daily dosage of oral antiplatelet agents (80 mg aspirin and 75 mg clopidogrel). After a thorough discussion with the patient and a medical consultation, it was decided not to stop the anticoagulation therapy for the DSEK.
An informed consent was obtained, and the patient underwent DSEK in her left eye under retrobulbar anesthesia. Briefly, a 5.5 mm scleral tunnel wound was created 2 mm behind the temporal limbus. The Descemet membrane was scored and stripped under viscoelastic cover. A 7.5 mm donor endothelial lenticule was folded in a 60/40 taco and inserted in the anterior chamber with a pair of forceps. At this stage, the surgeon noticed bleeding into the anterior chamber from the root of iris. The viscoelastic cover and blood were gently irrigated, and the anterior chamber was filled with air at the end of the surgery. Postoperatively, the patient was instructed to lie supine. Topical 1% methylprednisolone eye drops six times a day and 0.5% moxifloxacin eye drops four times day were prescribed. Oral dose of 250 mg of acetazolamide three times a day was given for the first 2 days after the surgery.
On the first postoperative day, visual acuity was hand motion in the operated eye. The donor lenticule was well apposed to the overlying corneal stroma. There was hemorrhage between the graft and the host, covering most of the interface area (Fig. 1A). The details of anterior chamber were not clear. Left eye IOP was 24 mm Hg. Topical 0.15% brimonidine twice daily was added to the postoperative treatment, and a bandage contact lens was inserted to augment healing of the corneal epithelial defect. There was no change in the amount of interface hemorrhage by the end of 3 days postoperatively, although the IOP returned to the baseline level. On postoperative day 4, irrigation of the donor-host interface was carried out in the operating room under local anesthesia. The interface blood was irrigated with balanced salt solution using a 30 G cannula mounted on syringe. The anterior chamber was filled with air at the end of the procedure. The patient was examined under slit lamp 2 h later, and the donor-graft interface was found to be clear. Similar postoperative treatment regimen was continued. However, slit lamp examination on the following day showed hemorrhage in the interface again, and the left eye visual acuity remained motion close to face (Fig. 1B). Donor lenticule was well apposed to the corneal stroma. At this stage, it was decided not to perform any further surgical interventions to avoid any potential damage to the donor endothelium or further potential trauma to the iris. Weekly follow-ups were scheduled for the patient. Corticosteroid eye drops were continued four times a day in the operated eye.
Over the next 4 weeks, the interface blood gradually started to clear from the central cornea. At the end of 6 weeks postoperatively, the interface hemorrhage was limited to the inferior two-thirds of the cornea, and the BCVA improved to 20/200 (Fig. 1C). Subsequently, the hemorrhage disappeared completely at the 4-month follow-up, and a BCVA of 20/80 was achieved in the operated eye (Fig. 1D). Fundus examination showed age-related macular changes. Specular microscopic examination showed an endothelial cell density of 1375 cells/mm2. Patient was advised to continue corticosteroid eye drops twice daily along with preservative-free artificial tear drops four times a day. The vision and graft remained clear and stable over time. At the last follow-up (8 months), the endothelial cell density was 1197 cells/mm2 and IOP was 12 mm Hg in the operated eye.
The surgical technique for DSEK has undergone various modifications since its conception to reduce the incidence of intraoperative and postoperative complications.1,2 Complication rates in literature are variable and dependent on the experience of surgeons, patients' factors, and the surgical techniques used.1–8 In a case file analysis of 118 patients undergoing DSEK, Suh et al. reported a myriad of complications, including retinal detachment, cystoid macular edema, epithelial ingrowth, and retained blood, at the donor-host interface.3 Other less commonly reported complications include lamellar disc and intraocular lens dislocation into the vitreous cavity, herpetic keratitis, retrocorneal fibrous membrane, and aqueous misdirection syndrome.3–7 Unlike laser in situ keratomileusis surgery, where washing of the interface blood between the flap and stromal bed is relatively less invasive, the management of extensive interface hemorrhage after DSEK can be challenging and has not been clearly addressed in the past. Interface hemorrhage is a known complication of lamellar corneal surgeries. Persistent blood in the graft-host interface may be associated with development of late corneal haze and a subsequent decrease in visual performance and acuity. Schmitt et al.8 recently reported a case with intraoperative interface bleeding from a peripheral iridotomy during DSEK. Repeated attempts were made to wash the interface during the surgery. Ultimately, the patient was treated with periodic observation, and the interface was cleared by the end of 8 months.
In our case, the surgeon noted bleeding from the root of iris intraoperatively. Although it appeared that bleeding stopped during the surgery, we encountered a dense interface hemorrhage in the immediate postoperative period. Interface irrigation was attempted, but the hemorrhage reappeared, possibly owing to the continuation of systemic antiplatelet therapy. The concurrent use of two anticoagulant drugs was a major contributing factor for intraoperative bleeding in the first place. Patients receiving long-term antiplatelet and anticoagulant medications pose a clinical challenge at the time of intraocular surgery. If anticoagulation is continued, there is a risk for bleeding complications. However, if these medications are discontinued, there is a risk for thromboembolic complications.9,10
A majority of the studies in ophthalmic literature commenting on the use of anticoagulation therapy pertain to cataract surgery. Kobayashi reported a higher incidence of hyphema and retinal hemorrhage in patients on anticoagulants undergoing cataract surgery than those who discontinued therapy, although the difference was not significant.11 In a study by Kumar et al., patients on antiplatelet or anticoagulant therapy had significantly more frequent subconjunctival hemorrhages than those not following a therapeutic regimen.12 Patients using clopidogrel, with or without aspirin, were shown to have a higher rate of subconjunctival hemorrhage in a large data set from the United Kingdom.13
Koenig has reported the occurrence of an extensive suprachoroidal hemorrhage on first postoperative day in a patient after DSEK in the setting of continued systemic anticoagulation.14 In our case, we could not stop the anticoagulant therapy owing to severity of ischemic cardiac disease and previous history of coronary angioplasty. Because the graft was well positioned and well apposed to the corneal stroma, after discussion with the patient, it was decided to continue conservative management for the interface hemorrhage. Over a period of the next 4 months, the interface cleared spontaneously, and a BCVA of 20/80 was achieved without any significant endothelial damage. Visual acuity did not improve further owing to age-related macular changes and peripapillary atrophy.
Our case report highlights that even after extensive interface hemorrhage after DSEK in a patient on systemic anticoagulant therapy, spontaneous clearing was still possible, with good graft function recovery. One attempt to drain the interface blood was made, but recurrent bleed was encountered. We believe that in the absence of graft dislocation, it might be prudent in such cases to wait for the resolution of the interface blood while continuing conservative management and a close follow-up. Surgeons should be aware of the risks of continued anticoagulation treatment in patients undergoing keratoplasty. More experience in diagnosis and management of such complications would be desirable from other corneal surgeons around the world.
Alvin L. Young
Department of Ophthalmology and Visual Sciences
The Chinese University of Hong Kong, Prince of Wales Hospital
Shatin, Hong Kong, People's Republic of China
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cornea; keratoplasty; hemorrhage