Inadvertent stromal staining simulating a Descemet membrane endothelial keratoplasty graft : Indian Journal of Ophthalmology

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Inadvertent stromal staining simulating a Descemet membrane endothelial keratoplasty graft

Bhargava, Mona; Nathani, Karan; Paul, Raj Shekhar

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Indian Journal of Ophthalmology 70(12):p 4107, December 2022. | DOI: 10.4103/ijo.IJO_2060_22
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Inadvertent stromal staining was noted after anterior chamber wash during trypan blue staining of the anterior capsule done intraoperatively in a 55-year-old female undergoing right eye cataract surgery. An interface of suspected Descemet membrane (DM) separation was also noted in the form of DM striae. Considering poor visibility, the surgery was stalled and an air bubble was injected into the anterior chamber, following which the case was closed for postoperative analysis.

Stromal staining was confined to the central 8-mm area, with DM striae, simulating the appearance of DMEK graft after Descemet Membrane Endothelial Keratoplasty (DMEK) surgery with trypan blue-stained disc of 8 mm apposed centrally [Fig. 1c].

Figure 1:
(I) Digital photograph of the anterior segment of the right eye showing diffuse stromal staining under diffuse illumination at postoperative day 1 (a) and clear cornea at 2 weeks (e). (II) High-resolution, cross-sectional corneal image (ASOCT) of the right eye showing DM separation on postoperative day 1 (b, red arrow), Descemet membrane detachment at 1 week (d, red arrow) and resolved DM detachment at 2 weeks (f, red arrow). (III) Digital photograph of the anterior segment of the right eye showing stained DMEK graft (c) simulating as corneal staining as image A

Next Step

  1. Anterior segment optical coherence tomography (ASOCT) to rule out DM detachment (DMD)
  2. Treat conservatively with topical steroids
  3. Hypertonics
  4. All of the above.

Clinical Findings

On postoperative (postop) day 1, there were DM striae with corneal stromal staining [Fig. 1a]. On postop day 1, ASOCT showed DM separation [Fig. 1b] which was very well-delineated as DM detachment on day 7 [Fig. 1d]. On postop day 1, the patient also underwent specular microscopy (cell density of the right eye being 1723 mm2, and of the left eye 2966 mm2) and pachymetry (right eye = 461microns, left eye = 470 microns) examinations. The patient was treated with topical steroids and hypertonic saline. DM detachment settled with conservative management.

At two-week follow-up, cornea was clear and the DM was found well-apposed. both clinically and on ASOCT [Fig. 1e and f]. The best-corrected visual acuity returned to preoperative 20/40. Three weeks later, the patient underwent uneventful cataract surgery.


Inadvertent stromal staining.

Correct answer

d. All of the above.


An accidental injection of trypan blue into the corneal stroma could have happened due to multiple reasons like faulty focusing of the microscope, poor stereopsis of the operating surgeon, lack of surgical experience, misdirection of the cannula during injection of trypan blue, use of blunt instruments, improper wound construction, and repeated instrument maneuvering through the side port.[1] Endothelial evaluation did not reveal any guttate changes, thereby ruling out any preexisting pump malfunctions as noted in Fuchs’ corneal dystrophy.

The role of ASOCT in diagnosing DM detachment in the presence of corneal edema and its resolution post treatment has been very well-documented.[2] In our case, stromal staining was accompanied by DM detachment, which has not been reported earlier. DM detachment was managed conservatively and it resolved within two weeks. ASOCT is an indispensable tool in the setup of corneal edema or staining to rule out the presence of DMD. Early identification leads to timely management in the form of intraoperative air descemetopexy or postoperative topical steroids and hypertonics.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. Nandini C, Matalia H, Zameer L, Matalia J. Corneal staining during cataract surgery:Natural course, ASOCT features, and preventive measures. Indian J Ophthalmol 2019; 67:557–9.
2. Hurmeric V, Yoo SH, Mutlu FM. Optical coherence tomography in cornea and refractive surgery. Expert Rev Ophthalmol 2012; 7:241–50.
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