A 75-year-old female patient presented for follow-up 9 months after a PK in the left eye.
She had undergone a deep sclerectomy for open-angle glaucoma 12 years prior to the keratoplasty followed by cataract surgery 3 years later and a Baerveldt tube implantation, due to medically uncontrolled intraocular pressure, 5 years later. Implantation of the Baerveldt tube was performed in the sulcus to avoid any corneal touch. She had also been treated for recurrent anterior uveitis. Uveitic workup was negative for sarcoidosis, syphilis, lyme, and tuberculosis. As herpetic origin could not be excluded, patient was treated with prophylactic systemic valaciclovir to avoid recurrence.
One year after the last surgery, patient presented with endothelial decompensation and stromal edema. A DMEK was performed under local anesthesia, without any intraoperative complication. Postoperative treatment consisted of dexamethasone and ofloxacin drops four times a day. Valaciclovir was continued. One month after surgery, the patient presented with total corneal opacification, stromal edema, and graft failure. After 2 months, she developed anterior stromal fibrosis. A PK was planned. A 7.75 mm graft was sutured after a 7.5 mm trephination. The postoperative treatment included dexamethasone and tobramycine drops (Tobradex ; Alcon, Fort Worth, TX, USA) six times a day. Valaciclovir was continued. No postoperative complication was recorded for the first 9 months.
Nine months after the surgery, the patient presented with anterior peripheral synechiae involving the graft for three clock hours. Peripheral native cornea appeared totally opaque (Figure 1). Graft was clear with no sign of rejection. Anterior chamber was calm, with no sign of recurrent uveitis. Intraocular pressure was 15 mmHg.
Because of the history of uveitis, synechiolysis was planned. Surgery was performed under local anesthesia and was assisted by Leica enfocus Ultra deep OCT (Leica Microsystems, Wetzlar, Germany), which delivers high definition real-time images of the anterior segment. Due to peripheral corneal opacification, anterior synechiae could not be properly seen with slit lamp microscopy or operative microscope. Intraoperative OCT allowed us to detect nonclinically visible synechiae and to confirm complete synechiolysis immediately after surgery (Figure 2). Synechiolysis was performed using a viscoelastic cannula (Viscoat , Alcon, Fort Worth, USA) and an ophthalmic dispersive device (Viscoat).
No postoperative complication was recorded. Postoperative treatment included tobramycine and dexamethasone drops six times a day for 3 months with progressive tapering. Valaciclovir was continued 1 g three times a day for 1 month and then tapered weekly until 500 mg per day. Two months after the surgery, vision was 0.2 limited by advanced glaucomatous neuropathy. The graft was clear and anterior segment OCT (Spectralis, Heidelberg, Germany) did not reveal any residual synechiae or recurrence.
Written informed consent has been provided by the patient for the publication of her case details and images.