Complex Deep Lamellar Endothelial Keratoplasty for Complex Bullous Keratopathy With Severe Vision Loss

Purpose: To determine the efficacy and postoperative complications of complex deep lamellar endothelial keratoplasty (DLEK) when used for the management of complex bullous keratopathy with severe vision loss. Methods: Twelve consecutive eyes with severe bullous keratopathy and other associated intraocular abnormalities underwent complex DLEK which was combined with other intraocular surgeries such as vitrectomy, intraocular lens removal, and secondary intraocular lens implantation. An air bubble was used in 9 eyes and an air and C3F8 gas bubble in 3 eyes for tissue support. Prospective data of best spectacle-corrected visual acuity, corneal astigmatism, and curvature were collected on all 12 eyes preoperatively and at 6, 9, and 12 months postoperatively. Average donor endothelial cell density was recorded preoperatively and at 9 months postoperatively. Results: Preoperatively, severe visual loss was recorded at hand motions (n = 3), count fingers (n = 7), and 20/400 (n = 2). Best spectacle-corrected visual acuity improved in 83% of eyes with vision of 20/67 or better in 42% (5/12) and 20/100 or better in 66% (8/12) of eyes at 12 months postoperatively. Vision was not improved in three eyes due to coexistent retinal disease. Four aphakic eyes underwent secondary intraocular lens implantation later at 4-6 months after DLEK, and best spectacle-corrected visual acuity was increased from count fingers to 20/200 or better. At 12 months postoperatively, average corneal astigmatism and curvature were 2.3 ± 0.5 diopters and 44.0 ± 0.9 diopters, respectively. Average central corneal thickness at 12 months postoperatively (541.3 ± 26.7 μm) was significantly thinner than that before surgery (673.8 ± 77.5 μm, P < 0.01). Preoperative average donor endothelial cell density was 2685.1 ± 193.9 cells/mm2. At 9 months postoperatively, average endothelial cell density was 1920.1 ± 94.0 cells/mm2 (27.3% of endothelial cell loss) in eyes with primary surgery and 1866.3 ± 92.8 cells/mm2 (33.9% of endothelial cell loss) in eyes with secondary surgery. Postoperative complications usually occurred within 3 months of surgery. After surgery, 3 eyes showed narrow gaps between the border of the graft and the host. Epithelial bullae in these areas recurred in 2 eyes but disappeared within 3 months. There was one graft dislocation in this series, no pupillary block cases, and no primary graft failures. Conclusions: In cases of complex bullous keratopathy with severe vision loss, DLEK combined with other intraocular surgeries is a feasible and effective procedure to significantly improve visual acuity to a functional level in most patients. DLEK can be used successfully in eyes with aphakia and other anterior segment abnormalities without a high risk of graft dislocation or failure. Mild postoperative complications usually occurred early after DLEK and did not affect visual outcomes and graft survival if managed appropriately.