Corneal neovascularization is the final outcome of many corneal diseases and is considered a relative contraindication to penetrating keratoplasty (PKP). Descemet-stripping automated endothelial keratoplasty (DSAEK) may be considered in some corneal neovascularization cases because only the inner corneal lamella is transplanted, with minimal disturbance to the outer vascularized anterior lamella.1 We present a case of complete regression of severe corneal neovascularization following a combined triple procedure of phacoemulsification, intraocular lens (IOL) implantation, and DSAEK.
A 75-year-old woman of Ethiopian origin presented with long-standing bullous keratopathy diagnosed as late sequela of Fuchs endothelial corneal dystrophy. The right eye was pseudophakic with cornea guttata, but the cornea was clear and the corrected distance visual acuity was 6/30 with −3.50 +1.50 × 145. The vision in the left eye was limited to light perception, and the intraocular pressure (IOP) was 12 mm Hg. A complete eye examination was remarkable for severe corneal edema with extensive stromal neovascularization, which precluded visualization of other intraocular structures (Figure 1). B-mode ultrasound imaging of the left eye showed that the retina was attached. There was no evidence of associated afferent pupillary defect.
After various available therapeutic options were considered, a triple procedure including phacoemulsification, IOL implantation, and DSAEK was proposed for the left eye. Briefly, after the corneal epithelial cells were removed and topical dextrose 50% was applied to dehydrate and clear the cornea for better visualization of the intraocular structures, standard phacoemulsification using trypan blue to stain the anterior capsule and the vertical chopping technique was performed with the help of fiber-optic illumination. The main incision was sutured. Descemet membrane was removed under air using a bent 25-gauge needle. The corneal graft was implanted using a Busin glide and an intraocular forceps. All the incisions were sutured, and the anterior chamber was filled with air. A mild toxic anterior segment syndrome developed during the first postoperative days, which was resolved with topical steroid treatment. There were no other sequelae.
The postoperative eye examination showed the graft was centered and clear and the cornea had become transparent. At the 6-week follow-up, the neovascularization had regressed completely, leaving only ghost vessels. At 9 months, the cornea remained clear with only ghost vessels and the uncorrected distance visual acuity was 20/60 (Figure 2).
We report a case of complete regression of severe corneal neovascularization at 6 weeks following a successful triple procedure of phacoemulsification, IOL implantation, and DSAEK. Corneal neovascularization is considered a relative contraindication to PKP because it significantly increases the risk for graft rejection and graft failure as a result of the violation of the local corneal immune privilege. In a recent meta-analysis of 24 000 PKP cases, the overall risk ratio for graft failure due to corneal neovascularization was 1.32, whereas the overall risk factor for graft rejection was 2.07.2 Many approaches to eliminate or reduce corneal neovascularization have been investigated, including anti-vascular endothelial growth factor (VEGF) antibodies given in ophthalmic drops or injected subconjunctivally, light argon laser applications to deep stromal vessels, scraping the corneal epithelium and scleral feeding vessels, and photodynamic therapy. All have had limited, if any, success.1,2–5 Unlike PKP, inner lamellar corneal transplantation, such as DSAEK, may be considered in some corneal neovascularization cases because only the inner corneal lamella is transplanted; ie, there is minimal disturbance to the outer vascularized anterior lamella.
Our patient’s corneal neovascularization was probably the result of chronic corneal edema and chronic inflammation, which resulted in increased stimulation for the development of corneal neovascularization. The successful DSAEK procedure restored the endothelial pump mechanism and dehydrated the edematous cornea, reducing the chronic inflammation and leading to regression of the corneal neovascularization.
In conclusion, despite the increased risk for graft rejection, we suggest that posterior lamellar corneal transplantation such as DSAEK be considered in cases of severe corneal neovascularization. Our patient had a triple procedure without adjuvant use of anti-VEGF, laser, or antimetabolites, and the corneal neovascularization completely regressed. The visual acuity improved from light perception to 20/60 within 6 weeks. It is important to emphasize that DSAEK has the potential to regress corneal neovascularization only in cases in which endothelial dysfunction is the underlying cause of the neovascularization. It will not work in other cases of failed cornea and neovascularization. Further research is necessary to assess the benefits of posterior lamellar corneal transplantation in patients with severe corneal neovascularization.
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