Sir,

In Descemet-stripping automated endothelial keratoplasty (DSAEK), graft preparation is done with a mechanical microkeratome.1 Interface corneal metallic deposits due to the microkeratome dissection have been described after LASIK2 but have not been described with DSAEK. We report a case of post DSAEK patient with long-term presence of presumed metallic particles in the interface.

Case report

A 75-year-old female presented with bilateral Fuchs dystrophy and nuclear sclerosis, worse in her right eye. She underwent planned phaco-emulsification, foldable three-piece IOL implantation with DSAEK in right eye. DSAEK donor tissue was prepared by eye bank with automated microkeratome. The procedure was performed by a technique described elsewhere.3 There were no intraoperative complications. After 1 week, slit-lamp examination revealed donor disc in place, and clear and compact cornea. Presence of multiple brightly reflective particles was observed in interface. There was no associated anterior chamber reaction or subjective symptoms. In the last follow-up visit, 18 months postoperatively, corrected visual acuity was 20/25 with compact and clear cornea. Interface particles were unchanged and character of brightly reflective deposits was unaltered (Figure 1).

Figure 1
figure 1

(a) Slit-lamp examination at 18 months showing characteristic metallic interface deposits scattered diffusely between host and graft. (b) Slit view showing the level of deposits in the DSAEK interface.

Full size image

Comment

To our knowledge this is the first report of presumed metallic particles in host-graft interface after DSAEK. Absence of anterior chamber reaction, reflective nature, wide area of deposition, and no change with topical steroids excluded possibility of intralamellar keratitis, epithelial downgrowth, or infectious etiology. Especially the reflective nature, sharp borders of particles and inert nature were similar to the metallic deposits described in interface after LASIK. In previous studies, microkeratome-related blade shattering leading to deposits of metallic debris have been described in LASIK.2 Wave-like deposition of debris in DSAEK interface with presumed origin from microkeratome4 and small particles observed only in confocal microscopy5 have been reported in previous studies after DSAEK. In our case, the reflective nature of the slit-lamp observed debris was suggestive of metallic origin, which did not seem to affect the visual outcome in 18 months follow up. Confocal microscopy was not available. In the future, femtosecond laser technology may provide thinner, better quality grafts and in addition will avoid microkeratome-related interface debris.