Case series and techniques of Descemet’s Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury
Kobayashi et al. BMC Ophthalmology
Case series and techniques of Descemet's Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury
Akira Kobayashi 0
Hideaki Yokogawa 0
Natsuko Mori 0
Kazuhisa Sugiyama 0
0 Department of Ophthalmology, Kanazawa University Graduate School of Medical Science , 13-1 Takara-machi, Kanazawa-shi, Ishikawa-ken 920-8641 , Japan
Background: To evaluate clinical outcomes of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth. Case presentations: Four eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm2 (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively. Conclusions: In this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber.
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Background
Descemet’s Stripping Automated Endothelial Keratoplasty
(DSAEK) is widely performed as a preferred treatment of
endothelial dysfunction [1–5]. DSAEK completely
eliminates any surface corneal incisions or sutures, maintains
much of the structural integrity of the cornea and induces
minimal refractive change, suggesting distinct advantages
over standard penetrating keratoplasty (PK) [6, 7].
However, DSAEK requires a completely smooth host corneal
rear surface since only air pressure is used for donor
attachment. Therefore, endothelial surface irregularity is
one of the contraindications of DSAEK.
Forceps delivery is sometimes performed in the course
of vaginal childbirth when the mother and/or baby are
having difficulties during the pushing stage of labor. In a
forceps delivery, a doctor applies forceps, an instrument
shaped like a pair of large spoons or salad tongs, to the
baby's head to help guide the baby out of the birth canal.
One complication of a forceps delivery is that the baby’s
Descemet’s membrane can be damaged, which causes
late corneal endothelial failure with an irregular endothelial
surface [8].
In this report, clinical outcomes and detailed surgical
tips of DSAEK (and phacoemulsification of concomitant
cataract surgery) for severe bullous keratopathy due to
endothelial injury after forceps delivery are presented.
Also, this report highlights surgical techniques to enhance
visualization of severe bullous change in cases of birth
injury with or without simultaneous cataract surgery. This
information may be useful for DSAEK not only in cases
with corneal birth injury, but also in similar corneal
endothelial pathologies with severe bullous keratopathy.
Case presentations
Patients
This prospective, non-comparative study was approved by
the Ethical Committee of Kanazawa University Graduate
School of Medical Science and followed the tenets of the
Declaration of Helsinki. Written informed consent was
obtained from all patients for publication of this Case
report and any accompanying images. Four eyes (four
patients; mean age, 51.5 years) with bullous keratopathy
as a late complication of endothelial injury after forceps
delivery at birth were enrolled (Table 1, Fig. 1). All patients
had amblyopia from childhood due to cloudy cornea.
Therefore, the diagnosis of endothelial injury due to
forceps delivery was already made at childhood by
characteristic Descemet’s membrane breaks (Haab’s striae).
Nontheless, DSAEK was indicated in these patients later in
their lives for the irritation and severe light sensation
caused b (...truncated)