Histologic evidence of retained fetal layer of the Descemet membrane after presumed total removal for endothelial keratoplasty - A possible cause for graft failure

Purpose: This is, to our knowledge, the first report of histology after failed Descemet-stripping endothelial keratoplasty (DSEK) surgery in a patient. We describe the interface histology found in a case of donor nonadherence and subsequent graft failure in a patient after DSEK. Methods: An 83-year-old woman with a history of Fuchs dystrophy underwent DSEK surgery and subsequently underwent full-thickness penetrating keratoplasty (PKP) because of nonadherence of the donor disc and presumed graft failure. Specimens from the initial stripping of the Descemet membrane, the failed donor disc, and the full thickness of the patient's remaining cornea containing the recipient bed after her DSEK and PKP procedures were histologically evaluated by light microscopy. Results: Microscopic examination of the initial stripped recipient Descemet membrane revealed a delamination of the Descemet membrane involving the fetal layer. After PKP, histopathologic study of the recipient button revealed residual fetal Descemet membrane retained on the recipient DSEK interface. Examination of the failed donor disc showed healthy tissue. Conclusions: In DSEK surgery, there are multiple reasons that the donor graft button may fail to adhere to the recipient posterior corneal surface. In this instance, histologic study revealed that the Descemet membrane was split by the stripping, and the fetal layer of the Descemet membrane was retained on the central part of the patient's posterior cornea. Despite histologically normal donor endothelial cells, the inability of the donor tissue to adhere may have been caused by the coating of the central recipient bed with retained fetal Descemet membrane.