Sweating of Descemet's membrane during deep anterior lamellar keratoplasty in absence of perforation

Karim Mohamed-Noriega,^1,2 Jodhbir S Mehta<sup>1–4

1</sup>Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, ²Corneal and External Disease Service, Singapore National Eye Centre, ³Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, ⁴Department of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore

Abstract: We report a case of spontaneous Descemet's membrane sweating of aqueous humor during a manual deep anterior lamellar keratoplasty (DALK) without perforation of Descemet's membrane. An 81-year-old female developed a neurotrophic central ulcer with descemetocele in the right eye, and her visual acuity was count fingers at 30 cm. She was unresponsive to medical treatment, and an uneventful manual DALK was performed. Six months after surgery, unaided visual acuity improved to 6/30. Seven months after surgery, the patient had a decrease in visual acuity to count fingers in the same eye. She was diagnosed as having corneal melting with a central descemetocele in the previous lamellar graft. A repeat manual DALK graft was performed. Lamellar dissection was performed starting from the edge of descemetocele, proceeding to the corneal periphery and maintaining the surgical plane of the previous DALK. During the surgical procedure, continuous and localized sweating of aqueous through Descemet's membrane was observed in the area of the descemetocele. After drying of the recipient bed, no visible perforation of Descemet's membrane was found. After removal of the previous DALK graft, a new stromal lamellar graft was sutured. The surgery was concluded without complications. One day after surgery, the graft was clear, with no detachment of Descemet's membrane. If Descemet's membrane sweating is observed during DALK and there is no visible perforation, the reason may be a hidden micron perforation in an intact Descemet's membrane. It is recommended to continue with surgery maintaining maximum diligence and low intraocular pressure to prevent extension of micron perforation.

Keywords: deep anterior lamellar keratoplasty, perforation, Descemet's membrane, sweating