Abstract
Purpose
To report the use of Descemet Membrane Endothelial Keratoplasty (DMEK) for secondary surgical removal of intraocular foreign bodies (IOFB) years after the trauma as migration occurred through the endothelium, damaging the endothelium, and causing corneal edema.
Observations
We report the case of a blast injury in 1972, that led to left eye traumatic cataract managed with vitrectomy and lensectomy. Although thorough removal was attempted, some corneal and conjunctival foreign bodies remained.
Despite aphakia, the patient maintained acceptable best corrected visual acuity (BCVA) (0.30 LogMAR) but >30 years later, experienced visual deterioration. IOFB protruding through the Descemet membrane (DM) were seen, with extensive edema. Descemet Membrane Endothelial Keratoplasty was performed in an attempt to treat the endothelium and remove the foreign bodies protruding through the DM. The procedure was done uneventfully under sulfur hexafluoride gas (SF6) and the patient improved. Four years after the surgery, BCVA was 0.63, however, 6 years later, a new episode of migrating intracorneal foreign bodies with corneal edema reduced BCVA to 0.40. The decision was made to observe the patient, and delay a second DMEK.
Conclusions and importance
Corneal decompensation caused by IOFB breaching the Descemet membrane can safely be managed with a DMEK. DMEK is feasible even in complex cases and should be attempted due to its lower risk of graft rejection and likely benefits, while saving the option of more aggressive transplantation techniques, such as penetrating keratoplasty, in cases of failure.
1
Introduction
When possible, an intracorneal foreign body should be immediately removed to prevent further injuries, inflammation, or even infection, but after the immediate period, it has been well documented that foreign material remnants may remain for years without causing any complications. Secondary surgical removal years after the original trauma might be performed when complications such as edema, inflammation, astigmatism, or corneal opacities occur, due to the migration of the intracorneal foreign body. Closed-globe blast injuries are poorly documented but studies reported corneal and ocular surface involvement in up to 25% with Descemet Membrane (DM) rupture in 6 out of 65 eyes, accompanied by endothelial cell loss. , If the damage to the cornea and DM is extensive, endothelial cell loss may lead to corneal decompensation warranting corneal transplant. We report the case of a blast injury resulting in multiple intracorneal foreign bodies and secondary corneal decompensation after migration through the Descemet membrane 39 years after the trauma, successfully treated with Descemet Membrane Endothelial Keratoplasty.
2
Case report
A 63-year-old male patient with blast injury caused by an explosive mine in 1972 suffered from right eye exenteration and left eye traumatic cataract. At the time, the left eye underwent vitrectomy and lensectomy, and was later diagnosed with glaucoma treated by topical betablockers. Despite left eye aphakia, the patient maintained acceptable best corrected visual acuity (BCVA) (0.30 LogMAR). In the recent years, the patient was experiencing left eye visual deterioration, which was worse in the morning, attributed to corneal edema, and was referred to our tertiary center for second opinion, 39 years after the initial blast injury.
At presentation, left eye BCVA was 0.90 LogMAR (+2.50, −2.75 at 150°) with an intraocular pressure (IOP) of 14 mmHg. On slit-lamp examination, multiple (about 20) inframillimetric intracorneal (ICFB) and intraconjonctival foreign bodies were seen, with corneal decompensation and edema. In the anterior chamber, remnants of vitreous were noted. Gonioscopy did not reveal any angle foreign bodies. Detailed examination of the rest of the eye was not possible due to poor visibility and transparency, gross fundus examination seemed to exclude important posterior segment pathologies. B-Ultrasound ruled out retinal pathologies, including detachment. The patient wore a prosthesis in the right eye.
Investigations at presentation are displayed in Fig. 1 and revealed extensive corneal edema with central corneal thickness (CCT) at 832 μm (Visante ®, Zeiss), and intracorneal foreign bodies protruding through the DM at various levels on corneal optical coherence topography (OCT, Visante ®, Zeiss). No preoperative endothelial cell count was obtainable due to the massive corneal edema.
The decision was taken to perform a Descemet Membrane Endothelial Keratoplasty (DMEK) in an attempt to treat the endothelial decompensation, and remove the foreign bodies protruding through the DM.
The procedure was done uneventfully as previously described, , and was performed with sulfur hexafluoride gas (SF6). The foreign bodies were mainly of metallic origin with other hardly defined material, probably ceramic. Only the ones easily accessible during the surgery were removed, no attempts were done to remove the deep intrastromal ones. On day one ( Fig. 2 ) , the DM was correctly apposed with an IOP of 12. The patient was prescribed topical corticoid medication (4/day), and antibiotics (4/day) (for one week only) and corneal transparency was achieved at the 3-weeks-follow-up, where BCVA improved to 0.40 LogMAR (+3.00, −0.50 at 120°). Postoperative pachymetry and corneal OCTs showed gradual CCT diminution reduced to 645 μm. The patient was referred back to their primary ophthalmologist for the routine follow-ups.
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