Case Reports

Re-DMEK after glaucoma surgery

Case Report Details

First Author: M.Vokrojova CZECH REPUBLIC

Co Author(s):    L. Havlíčková   K. Samková   Z. Hlinomazová              

Abstract Details

Purpose:

Intraocular pressure (IOP) elevation can most often occur after Descemet Membrane Endothelial Keratoplasty (DMEK) due to corticosteroid therapy with steroid-induced IOP elevation and decompensation of pre-existing glaucoma. IOP elevation represents a high risk, which can lead to the endothelial cells damage and can cause graft failure. Thus, graft failure may appear earlier than it would in the original patient’s endothelium without transplantation. If local therapy is not sufficient and surgical treatment is needed to adjust IOP level, type of glaucoma treatment is chosen based on primary disease.

Setting:

European Eye Clinic Lexum, Prague, Czech Republic

Report of Case:

We present two cases. First case is a 35-year-old Caucasian man with iridocorneal endothelial syndrome (ICE). DMEK surgery was performed in the patient’s right eye in April 2015 in general anaesthesia. Preoperatively, UDVA was 0.05, IOP was normal, and a massive corneal edema was present. Postoperatively, CDVA was 1.0, IOP was 18 mmHg. Based on this diagnosis we started a local glaucoma therapy. In 2017 corneal edema appeared, together with worsened vision. IOP values were normal. Cataract progressed. In April 2017 the patient underwent a combined cataract and re-DMEK surgery in general anaesthesia. Postoperatively, CDVA was 1.0. Glaucoma treatment continued, during regular visits IOP did not exceed 19 mmHg. In March 2018 IOP increased substantially (between 28-35 mmHg). CDVA was 0.05. Local and general glaucoma therapy were without sufficient response. In May 2019 EX-PRESS was indicated, followed by a planned re-re DMEK (November 2019). Postoperatively, CDVA was 0.8. IOP was 14-18 mmHg with corticosteroid and glaucoma therapy. Last visit in March 2020 showed BCVA 0.8, and IOP 18 mmHg. Second case is a 54-year-old Caucasian man with posterior polymorphous corneal dystrophy (PPD). In November 2014, DMEK was performed in general anaesthesia in the right eye due to endothelial decompensation. Postoperatively, CDVA was 1.0, IOP was normal. In 2016 IOP elevation was treated using local glaucoma therapy, leading to normal and stable IOP values, and CDVA 1.0. In 2018 IOP elevation was observed, together with endothelial rejection, and cataract progression. The eye was treated using corticosteroids, and local and general glaucoma therapy. In April 2018 patient underwent cataract surgery followed by trabeculectomy (TE) in May 2018 and planned re-DMEK in July 2018. Postoperatively, CDVA was 1.0, IOP was 14-18 mmHg. During the last visit in February 2020, BCVA was 1.0, and IOP was 15 mmHg with local glaucoma therapy.

Conclusion/Take Home Message:

After DMEK surgery, a long-term corticosteroid therapy is needed, potentially resulting in a steroid secondary glaucoma. The eye may also develop a decompensated primary disease. Therefore, regular postoperative monitoring of accurate IOP, and a careful examination of optic nerve functions are essential. IOP elevation may result in the loss of nerve fibres and a progression of irreversible glaucoma changes. But, unlike endothelium, these nerve fibres may not be replaced. Thus, without precise IOP monitoring, even an uneventful re-DMEK surgery might not restore vision, because it has been irreversibly degraded due to elevated IOP. Concerning IOP measurement technique, immediately after DMEK, non-contact pneumatic tonometry (NCT) is not recommended. A more suitable technique seems to be a careful Goldmann applanation tonometry (GAT). In conclusion, reaching a normal and stable IOP is crucial when planning re-DMEK and trying to reach good outcomes and a functional graft after the surgery.

Financial Disclosure:

None