Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

Abstract

Purpose: To report how to manage a specific type of Descemet’s membrane (DM) rupture during manual DALK with a concurrent donor–recipient disparity of curvature. Methods: Case report of two patients that had DM rupture during manual DALK with a concurrent donor–recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a “DSEK autograft,” was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. Results: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). Conclusion: The existence of a donor–recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor–recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.