CORNEA EWAP MARCH 2022 41 surgery, generally, it is a postop complication. Dr. Price noted that it’s important to be careful during surgery if you have a case of an artificial iris. If you’re looking through a coaxial microscope, you get the impression you have a normal angle, which you don’t because there’s nothing in the angle, he said. The angle area goes out 12–13 mm, and artificial irises are typically 9–11 mm in diameter. If you put a DSAEK graft into one of those eyes and let go before putting an air bubble under it, it can fall into the back of the eye because it never got attached, he said. But generally during surgery, you shouldn’t get a detachment once you’ve filled the anterior chamber with air. Dr. Lin also highlighted considerations for patients with comorbidities or previous surgeries. She mentioned that she has found a higher rate of graft detachments with DSAEK in patients with comorbidities such as tube shunts, trabeculectomies, aphakia, or iris defects and anterior synechiae. With trabeculectomy and tubes, the air tends to escape faster than normal. If the patient has had a prior trabeculectomy or tube shunt, Dr. Lin will leave a much larger air bubble in the eye, maybe 90–100% air fill rather than the 80% she typically uses. Dr. Lin said she will discuss the potential problem of detachment with patients preoperatively. “I tell them that if it should happen, I can typically rebubble the graft in the office, or if that doesn’t work, we could do it in the OR, or worst case, repeat the transplant,” she said. EWAP Editors’ note: Dr. Lin is Associate Professor of Ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. Dr. Price is in practice with Price Vision Group, Indianapolis, Indiana. Neither declared any relevant financial interests. OCT of near total detachment. Note how the graft is curled on the right side; endothelium curls out so this is positioned the correct way and reinjecting air should push it into place. Source: Francis Price, Jr., MD Jacqueline Beltz, BMedsci, MBBS(Hons), FRANZCO Consultant Ophthalmologist, Eye Surgery Associates Level 2, 232 Victoria Parade, East Melbourne, Australia 3002 jacquelinebeltz@mac.com ASIA-PACIFIC PERSPECTIVES Firstly, I agree that corneal graft detachments happen to every corneal surgeon. This is a well-known complication that happens to the best of us! Patients need to be aware of the risk and surgeons need to be skilled at managing this problem. I probably have a lower threshold to re-inject air in the setting of DSAEK detachment than Dr. Price. While he is right, DSAEK can sometimes spontaneously reattach, I’ve found it to rarely happen for my patients. I like to see the transplant attached and clear from day 1. If it’s not, then I go back in to re-attach it as soon as possible. If the transplant isn’t clear, I look really carefully for a detachment as it can be quite subtle and easy to miss. Anterior segment OCT is helpful, but the double anterior chamber should be visible at the slit lamp with a thin bright beam, especially if you turn down the room lights. The exception for me would be when a DSAEK is clear, the patient is happy but I can see an area of detachment. This sometimes occurs in DSAEK under PK, where the center might be lovely and clear but there might be a space between the EK and the PK or host cornea peripherally. That often does improve over time and it doesn’t really matter if it doesn’t. I like to check my EK patients for attachment on Day 1 and Day 2. Most of the time, if there is going to be a detachment it will be apparent on Day 1. It’s very rare to detach after day 2 so I know that if it’s attached and clear at day 2 then we can move on. I have only had a couple of patients detach later than day 2 and then it might be associated with eye rubbing. I agree with Dr. Lin that re-bubbling at the slit lamp is difficult. While I have had success with this on occasion and many corneal specialists do this routinely, I think it’s difficult and often uncomfortable for the patient. I try to re-bubble in theater where possible. I absolutely agree with Dr. Price that hypotonous eyes are not good candidates for EK. Hypotony is the number one cause for detachment and can be a preexisting problem such as eyes with a history of glaucoma surgery or multiple comorbidities, but sometimes it can also be surgical. It’s really important to make sure all wounds are air and water tight at the end of surgery. I leave a full air fill for 2 hours and then release air after that to a level above my inferior peripheral iridectomy. The bottom line is that detachments do happen and as with most surgical complications, communication and planning are key. As Dr. Lin says, patients need to be aware of this possibility and plan for the possible return to theater, even though the chance is low. I also like to plan my own time. Even though detachment is rare, I like to have a strategy in terms of where and when I will re-bubble a transplant if it’s needed. Editors’ note: Dr. Beltz is a consultant for Alcon and Seqirus and an advisory board member for Novartis, AcuFocus, and Glaukos.
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