Re-bubbling may facilitate graft adhesion after DSEK

Br J Ophthalmol. 2011;95(11):1509-1512.

Issue: January 25, 2012

A re-bubbling technique successfully restored graft adhesion in a majority of eyes that had partial or complete graft detachment after undergoing Descemet's stripping endothelial keratoplasty, a study found.

"Descemet's stripping endothelial keratoplasty is a promising technique for endothelial dysfunction," the study authors said. "However, the surgery continues to evolve to address its own set of unique complications. The most common complication in the early postoperative period is graft dislocation/detachment, with reported incidences varying from 0% to 82% and with an average dislocation rate of 14.5%."

The retrospective study included 309 eyes that underwent DSEK from January 2009 to February 2010; 27 eyes of 27 patients (8.7%) developed graft detachment and underwent re-bubbling with air injection. The mean age of the 27 patients was 53.5 years.

The elapsed time from identification of graft detachment to re-bubbling ranged from less than 1 day to 4 days. All patients with complete or partial graft detachment underwent re-bubbling on the same day.

Study results showed that successful graft reattachment was achieved in 20 eyes (74%).

Clear grafts were attained in 13 eyes (65%), and seven eyes (35%) had primary graft failure. Visual acuity was 20/60 or better in six eyes (35%), 20/60 to 20/100 in four eyes (25%) and 20/100 or worse in 10 eyes.

Three of 10 lenticules that failed to attach with the first re-bubbling underwent a second re-bubbling, four successfully underwent repeat DSEK, and three underwent penetrating keratoplasty.

Vitrectomy performed in conjunction with DSEK was identified as a risk factor for persistent graft detachment after re-bubbling (P < .04), the researchers said.

This paper narrowly focuses on factors associated with attachment and clearing following an initial DSEK graft detachment and provides little information on how to modify practice patterns to achieve successful attachment in the first place. It would be interesting to know how the grafts that detached compared with those that attached successfully. More than half the grafts that detached were performed as combined procedures. In particular, grafts combined with anterior vitrectomy were less likely to attach and clear following an initial graft detachment. The suggested reason was that following a vitrectomy, the eye may develop hypotony when the patient sits up after supine positioning. However, the eye is a closed system and will not lose pressure when the patient sits up (even though the air bubble may move into the posterior chamber), unless there is a wound leak. Also, after an anterior vitrectomy, any remaining vitreous strands could interfere with graft adherence, but seeing them through a cloudy cornea could be difficult.

– Marianne O. Price, PhD
Executive Director, Cornea Research Foundation of America, Indianapolis
Disclosure: Dr. Price has no relevant financial disclosures.