Inadvertent Donor Button Inversion During Big-Bubble Deep Anterior Lamellar Keratoplasty

Purpose: The aim of this study was to describe clinical outcomes and histopathologic findings in a case of repeat deep anterior lamellar keratoplasty (DALK) performed because of inadvertent inversion of the donor button at the time of primary surgery. Methods: A 34-year-old woman underwent big-bubble DALK for keratoconus in her right eye; 4 days postoperatively, slit-lamp examination revealed the presence of several inclusions in the interface, whereas anterior segment optical coherence tomography (AS-OCT) showed pathologically marked wrinkling of the posterior stroma; inadvertent intraoperative inversion of the graft was diagnosed and the interface inclusions were assumed to be of epithelial origin. Repeat surgery was performed: donor tissue was removed and submitted to histological examination, marking the external surface of the lamella; the recipient residual bed was carefully washed and a new lamellar graft was sutured into position. Three months postoperatively, the patient underwent a complete ophthalmologic examination, including best-spectacle corrected visual acuity testing, refraction, biomicroscopy, AS-OCT, and endothelial microscopy. Results: Histological examination confirmed that the donor button had been implanted with the epithelium facing the residual bed. Three months postoperatively, normal corneal curvature was visible at AS-OCT, the best-spectacle corrected visual acuity was 20/25, and the interface appeared perfectly clear. Endothelial cell density had not been substantially affected by the 2 surgical procedures. Conclusions: Inadvertent inversion of donor tissue at the time of DALK is reported for the first time. Prompt exchange of the lamellar graft was instrumental in avoiding epithelial colonization of the interface, as well as in restoring excellent vision.