Posterior dislocation and early retrieval of a Descemet stripping automated endothelial keratoplasty graft

Posterior dislocation and early retrieval of a Descemet stripping automated endothelial keratoplasty graft | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Posterior dislocation and early retrieval of a Descemet stripping automated endothelial keratoplasty graft Philip Francis Stanley, Tun Hang Yeo, Jenny Chen Jue This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6432693/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: This case report seeks to document an rare case of posterior dislocation of Descemet stripping automated endothelial keratoplasty (DSAEK) graft in a patient with subluxed intraocular lens one day post operation. Observations: A 70-year-old man with a background of subluxed intraocular lens in a non-vitrectomized eye with pseudophakic bullous keratopathy underwent DSAEK. Review on post operative day one noted a posteriorly dislocated graft. Graft repositioning was done on the same day without complications. Conclusions and Importance: This case report shows the possibility of DSAEK graft dislocation post operation in a non-vitrectomized eye but with compromised barrier between anterior and posterior chambers of the eye. Descemet stripping automatic endothelial keratoplasty posterior Descemet stripping automatic endothelial keratoplasty graft dislocation subluxed intraocular lens Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Descemet stripping automated endothelial keratoplasty (DSAEK) is a partial corneal transplant which replaces only the posterior corneal tissue compared to penetrating keratoplasty (PK), which are full thickness corneal transplants. DSAEK is suggested to have faster visual rehabilitation and a lower risk of complications compared to PK. 1 Posterior graft dislocation is a known 2 post operative complication of DSAEK, with possible predisposing risk factors such as previous vitrectomy, aphakia or complicated intraocular lens placement. 3 We present a case of a 70-year-old gentleman with a background of subluxed intraocular lens but non vitrectomized eye with pseudophakic bullous keratopathy who underwent DSAEK and subsequently had a posteriorly dislocated graft. Case Report A 70-year-old Chinese male presented to Eye Clinic in November 2023 with blurring of vision with pain in left eye for 1 week. Patient has a known past ocular history of subluxed intraocular lens in the left eye which underwent cataract operation in 2012. There is no history of prior vitrectomy. On presentation, visual acuity of right eye is 6/7.5 + 2 while left eye was counting fingers closely. Intraocular pressure was 14mmHg on the right and 10mmHg on the left. On examination of the left eye, there noted to be bullous keratopathy with microcystic edema and severe Descemet membrane folds. Endothelial cell count by specular microscopy was 2506/mm 3 in the right eye and 749/mm 3 in the left eye. The anterior chamber was deep with occasional cells but no vitreous. The intraocular lens was subluxed but still in the iris plane. Examination of the right eye was normal. Patient underwent DSAEK of the left eye in March 2024. The donor tissue was obtained from Eversight, Chicago, Illinois with a death to preservation time of 11 hours and 48 minutes. Endothelial cell density was 2915 cells/mm 2 . Locally, the Singapore Eye Bank prepared the tissue. Pre and Post microkeratome cut endothelial cell density was 3030 cells/mm 2 and the graft thickness was 107 microns as measured by anterior segment OCT. Intraoperatively, the donor was cut to 8.0 mm. Graft insertion was done using the Tan ultrathin Endoglide. Anterior vitrectomy was necessary since vitreous was seen in the anterior chamber coming around the dislocated IOL. A 70% of air bubble provided good graft attachment. On review the day after operation, it was noted that the graft has separated with no air bubble seen (Fig. 1 ). The previously subluxed IOL was now dislocated. Re-bubbling was attempted at the slit lamp in clinic, but the air bubble went anteriorly to the graft and displaced graft through the pupil and into the posterior segment. The patient was then consented for pars plana vitrectomy (PPV) with intraocular lens (IOL) removal and DSAEK graft removal and repositioning the same evening. The DSAEK graft was retrieved during the PPV with micro forceps, brought through the pupil and reattached using a SF6 100% bubble). Post operative day one anterior segment OCT showed full graft attachment (Fig. 2 ). The graft remained well attached post operatively after the SF6 bubble dissipated. (Fig. 3 ). The patient underwent an uncomplicated secondary IOL surgery. Patient achieved VA of 6/15 + 2 in the right eye and 6/12 + 1 in the left eye 2 months post operation on 16 October 2024, with refraction achieving 6/7.5 + 2 in both eyes, with no improvement with pinhole. Figure 4 shows the latest anterior segment OCT. Figure 5 shows the most recent endothelial cell density. Figure 6 shows a slit lamp photograph showing a clear cornea and a well centred IOL. Discussion Graft dislocation is the most frequently reported complication after DSAEK due to potential causes such as interface fluid or air, minimal traction provided by smooth recipient interface for donor graft or patient squeezing or eye rubbing. 4 , 5 However, in patients with an insufficient barrier between the anterior and posterior chambers of the eye such as defects in the iris or lens capsule, there may be further possibility of posterior dislocation of DSAEK grafts into the vitreous cavity either intra-operatively or post-operatively. A literature review was done by looking at case reports on posterior dislocation of DSAEK grafts on PubMed with the findings summarised in Table 1. One of the strongest proposed risk factors for posterior dislocation of DASEK graft is the presence of a decompartmentalized eye affecting graft apposition. The proposed mechanism is that in a decompartmentalized eye, there is a loss of the closed system inside the anterior chamber with little turbulence. Fluid infusion via anterior chamber maintainer would lead to increased turbulence which causes the DSAEK graft to move from its intended position before the air bubble could be injected. 6 , 7 Air movement into the vitreous cavity could prevent sufficient maintenance of tamponade effect. 8 In our presenting case study, patient was noted to have a subluxed IOL with vitreous noted in the anterior chamber coming around the subluxed IOL, which suggested a breach in the closed system of the anterior chamber. Furthermore, the air bubble was noted to be approximately 70% post operatively but on post operative day one review, the previously subluxed IOL was dislocated and there was no air bubble seen, suggesting the likely migration of the air bubble into the vitreous cavity after the complete dislocation of the IOL, thus affecting the tamponade effect on the graft and causing graft dislocation. Further attempts to re-bubble the graft caused the graft to migrate posteriorly into the vitreous cavity due to the open communication between anterior and posterior segment from the dislocated IOL. To reduce the risk of graft dislocation in high-risk patients, putting temporary trans-corneal fixation sutures as part of the primary DSAEK procedure is a promising outlook with little complication and good graft adherence post operation. 9 Even in graft dislocation, placement of full thickness sutures over the detached area can help with good apposition. 10 When posterior graft dislocation arises, the timing for graft retrieval is crucial as there is a correlation between the time taken for graft retrieval and posterior segment complications such as cystoid macular edema or retinal detachment. In general, cases with graft retrieval at time of dislocation or within few days later were associated with no posterior segment complications while those with graft retrieval weeks after dislocation was associated with tractional retinal detachment. There are proposed mechanisms in how posterior dislocated graft can cause retinal detachment. Firstly, a histopathological study of failed DSAEK grafts noted pathological findings of fibrocellular tissue proliferation and epithelial ingrowth, which may predispose to graft adherence to retinal surface. The presence of transplanted foreign ocular tissue in vitreous cavity may evoke a severe inflammatory response which predisposes to early proliferative vitreoretinopathy. Hence, delayed removal of dislocated graft could result in further complications like retinal detachment. 11 We have presented a case study of an uncommon case of which a posterior dislocation of graft has occurred due the decompartmentalization of the eye following a dislocated IOL. Further research into this area can help to improve on current techniques of DSAEK to tailor towards patients at higher risk of posterior graft detachment as well as targeted management to reduce complications if detachment happens. Declarations Patient Consent Written consent to publish this case has been obtained. The patient has given written informed consent for their personal or clinical details along with any identifying images to be published in this study. Acknowledgments and Disclosures Funding: No funding or grant support Conflicts of Interest The following authors have no financial disclosures: PFS, YTH, JCJ Authorship All authors attest that they meet the current ICMJE criteria for Authorship Acknowledgements None Ethics Declaration Not applicable Availability of data and materials’ statement All data generated or analysed during this study are included in this published article and its references. References Kim SE, Lim SA, Byun YS, Joo CK. Comparison of long-term clinical outcomes between Descemet's stripping automated endothelial keratoplasty and penetrating keratoplasty in patients with bullous keratopathy. Korean J Ophthalmol. 2016;30:443–50. https://doi.org/10.3341/kjo.2016.30.6.443 . Suh LH, Yoo SH, Deobhakta A, Donaldson KE, Alfonso EC, Culbertson WW, O’Brien TP. Complications of Descemet's stripping with automated endothelial keratoplasty: survey of 118 eyes at one institute. Ophthalmology. 2008;115:1517–24. https://doi.org/10.1016/j.ophtha.2008.01.024 . Afshari NA, Gorovoy MS, Yoo SH, Kim T, Carlson AN, Rosenwasser GOD, Griffin NB, McCuen BW, Toth CA, Price FW, Jr M, Price MM, Fernandez. Dislocation of the donor graft to the posterior segment in Descemet stripping automated endothelial keratoplasty. Am J Ophthalmol. 2012;153:638–42. https://doi.org/10.1016/j.ajo.2011.09.006 . Price MO, Price FW. Descemet's stripping endothelial keratoplasty. Curr Opin Ophthalmol. 2007;18:290–4. https://doi.org/10.1097/ICU.0b013e3281a4775b . Suh LH, Yoo SH, Deobhakta A, Donaldson KE, Alfonso EC, Culbertson WW, O’Brien TP. Complications of Descemet's stripping with automated endothelial keratoplasty: survey of 118 eyes at one institute. Ophthalmology. 2008;115:1517–24. https://doi.org/10.1016/j.ophtha.2008.01.024 . Sng CA, Mehta J, Tan DT. Posterior dislocation and immediate retrieval of a Descemet stripping automated endothelial keratoplasty graft. Cornea. 2012;31:450–3. https://doi.org/10.1097/ICO.0b013e31823f76d5 . Grueterich M, Messmer E, Kampik A. Posterior lamellar disc dislocation into the vitreous cavity during Descemet stripping automated endothelial keratoplasty. Cornea. 2009;28:93–6. https://doi.org/10.1097/ICO.0b013e318183376b . Tanaka H, Hirano K, Horiguchi M. Wheel spokes technique for endothelial keratoplasty for extremely mydriatic bullous keratopathy eyes without capsular support. Case Rep Ophthalmol. 2018;9:238–42. https://doi.org/10.1159/000487705 . Papathanassiou M, Papaioannou L. Suturing technique to promote graft attachment in challenging cases of Descemet stripping endothelial keratoplasty. Open J Ophthalmol. 2015;5:124–9. https://doi.org/10.4236/ojoph.2015.53019 . Wu WK, Wong VWY, Chi SCC. Graft suturing for lenticule dislocation after Descemet stripping automated endothelial keratoplasty. J Ophthalmic Vis Res. 2011;6:131–5. https://doi.org/10.34172/jovr.2011.24 . Singh A, Gupta A, Stewart JM. Posterior dislocation of Descemet stripping automated endothelial keratoplasty graft can lead to retinal detachment. Cornea. 2010;29:1284–6. https://doi.org/10.1097/ICO.0b013e3181e84402 . Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table 1: DSAEK grafts on PubMed with the findings summarised. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6432693","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":472012179,"identity":"a89b1d8a-9536-4d4c-aff1-7b7dfb459fcb","order_by":0,"name":"Philip Francis Stanley","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIie3RPUvDQBjA8ecQ7HLS9aBivsKVQkUI3le5IOgSHKXjiXAuJ1krOvgppOOFrGe6Bs6h2bu4VbDgpcG4pMkqeP8hPAfPj7wB+Hx/MYJuNa9HpAFCCoB7idiRas+RS4r7yW6zIVk/OR3dCV0ugLHBm9YfcjlhowcNm9krBMlLKzl7ToWODEQKX/P0UdopPs45UsYCLVathBaRIxI4hphmR9KGmMT0AElHiO4kDA/XNNvK/JcE826ClNvMkNTThsBStL/LvCKGRKpY01TlFxP8btxgLKbFni9GrsrycxGyQRKPV5ub8/H9k3LDzJ4EyZ4Hqy5IkPqEDqH5UxgI7yI/x6+a1A3b7+Lz+Xz/rm+1DGjf47EIegAAAABJRU5ErkJggg==","orcid":"","institution":"Khoo Teck Puat Hospital","correspondingAuthor":true,"prefix":"","firstName":"Philip","middleName":"Francis","lastName":"Stanley","suffix":""},{"id":472012180,"identity":"881f2e5c-bafe-4fb1-9796-f076adbf0384","order_by":1,"name":"Tun Hang Yeo","email":"","orcid":"","institution":"Khoo Teck Puat Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tun","middleName":"Hang","lastName":"Yeo","suffix":""},{"id":472012181,"identity":"2fff9575-068f-4f00-b79a-2d2f1bffc333","order_by":2,"name":"Jenny Chen Jue","email":"","orcid":"","institution":"Khoo Teck Puat Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jenny","middleName":"Chen","lastName":"Jue","suffix":""}],"badges":[],"createdAt":"2025-04-12 06:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6432693/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6432693/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84857971,"identity":"d12b7122-dc37-4d3a-b075-e48406ff8eb9","added_by":"auto","created_at":"2025-06-18 06:28:25","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":271955,"visible":true,"origin":"","legend":"\u003cp\u003eAnterion photos showing DSAEK graft dislocation in the patient’s left eye on 7 March 2024.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/24b5d7b04ee8f11ecaab4fff.jpg"},{"id":84857974,"identity":"ea6c1964-8225-4c71-a9bf-36797393f8f8","added_by":"auto","created_at":"2025-06-18 06:28:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":208410,"visible":true,"origin":"","legend":"\u003cp\u003eAnterion photos showing DSAEK graft attached one day post operation of detached graft retrieval and reattachment done on 8 March 2024.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/60a7d346beae64e356a7baf7.jpg"},{"id":84857975,"identity":"d4b274a3-de4d-4516-8001-6e0bfbb6d3c7","added_by":"auto","created_at":"2025-06-18 06:28:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":314466,"visible":true,"origin":"","legend":"\u003cp\u003eAnterion photos showing DSAEK graft attached after the gas bubble dissipated on 11 March 2024.\u003c/p\u003e","description":"","filename":"FIG3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/654572a9a9950c2c9000561c.jpg"},{"id":84859921,"identity":"14e5dd0e-af44-4196-916a-553c83777c21","added_by":"auto","created_at":"2025-06-18 06:44:25","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":436581,"visible":true,"origin":"","legend":"\u003cp\u003eAnterion photo taken on 25 February 2025.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/9b2fdeeaf5a38c2a4730a989.jpg"},{"id":84858685,"identity":"d4bf19e1-0001-4c5a-9265-48444a959c78","added_by":"auto","created_at":"2025-06-18 06:36:25","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":378524,"visible":true,"origin":"","legend":"\u003cp\u003eSlit lamp photograph showing a clear cornea and DSAEK after secondary intraocular lens implantation taken on 25 February 2025.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/417929622d455f21d7fad29b.jpg"},{"id":84859922,"identity":"be183f5c-afa5-471a-9cf2-52322bc342a1","added_by":"auto","created_at":"2025-06-18 06:44:25","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":286942,"visible":true,"origin":"","legend":"\u003cp\u003eSlit lamp photograph showing a clear cornea and a well centred IOL.\u003c/p\u003e","description":"","filename":"Fig6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/9a0c9ef8a1923a4b0d870b84.jpg"},{"id":86620484,"identity":"07b35cdd-82d7-456b-92e7-5654421fbfdf","added_by":"auto","created_at":"2025-07-14 03:08:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2248376,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/94f6dad6-3847-4e2f-852d-35bc2f6423da.pdf"},{"id":84858687,"identity":"62b6e50a-ee0c-4fc0-ba40-4114c94eb60d","added_by":"auto","created_at":"2025-06-18 06:36:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":134800,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1: DSAEK grafts on PubMed with the findings summarised.\u003c/p\u003e","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6432693/v1/336f31f6485f8b2ae90b2e3a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Posterior dislocation and early retrieval of a Descemet stripping automated endothelial keratoplasty graft","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDescemet stripping automated endothelial keratoplasty (DSAEK) is a partial corneal transplant which replaces only the posterior corneal tissue compared to penetrating keratoplasty (PK), which are full thickness corneal transplants. DSAEK is suggested to have faster visual rehabilitation and a lower risk of complications compared to PK.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePosterior graft dislocation is a known\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e post operative complication of DSAEK, with possible predisposing risk factors such as previous vitrectomy, aphakia or complicated intraocular lens placement.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe present a case of a 70-year-old gentleman with a background of subluxed intraocular lens but non vitrectomized eye with pseudophakic bullous keratopathy who underwent DSAEK and subsequently had a posteriorly dislocated graft.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 70-year-old Chinese male presented to Eye Clinic in November 2023 with blurring of vision with pain in left eye for 1 week. Patient has a known past ocular history of subluxed intraocular lens in the left eye which underwent cataract operation in 2012. There is no history of prior vitrectomy. On presentation, visual acuity of right eye is 6/7.5\u0026thinsp;+\u0026thinsp;2 while left eye was counting fingers closely. Intraocular pressure was 14mmHg on the right and 10mmHg on the left.\u003c/p\u003e \u003cp\u003eOn examination of the left eye, there noted to be bullous keratopathy with microcystic edema and severe Descemet membrane folds. Endothelial cell count by specular microscopy was 2506/mm\u003csup\u003e3\u003c/sup\u003e in the right eye and 749/mm\u003csup\u003e3\u003c/sup\u003e in the left eye. The anterior chamber was deep with occasional cells but no vitreous. The intraocular lens was subluxed but still in the iris plane. Examination of the right eye was normal.\u003c/p\u003e \u003cp\u003ePatient underwent DSAEK of the left eye in March 2024. The donor tissue was obtained from Eversight, Chicago, Illinois with a death to preservation time of 11 hours and 48 minutes. Endothelial cell density was 2915 cells/mm\u003csup\u003e2\u003c/sup\u003e. Locally, the Singapore Eye Bank prepared the tissue. Pre and Post microkeratome cut endothelial cell density was 3030 cells/mm\u003csup\u003e2\u003c/sup\u003e and the graft thickness was 107 microns as measured by anterior segment OCT. Intraoperatively, the donor was cut to 8.0 mm. Graft insertion was done using the Tan ultrathin Endoglide. Anterior vitrectomy was necessary since vitreous was seen in the anterior chamber coming around the dislocated IOL. A 70% of air bubble provided good graft attachment.\u003c/p\u003e \u003cp\u003eOn review the day after operation, it was noted that the graft has separated with no air bubble seen (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The previously subluxed IOL was now dislocated. Re-bubbling was attempted at the slit lamp in clinic, but the air bubble went anteriorly to the graft and displaced graft through the pupil and into the posterior segment.\u003c/p\u003e \u003cp\u003eThe patient was then consented for pars plana vitrectomy (PPV) with intraocular lens (IOL) removal and DSAEK graft removal and repositioning the same evening. The DSAEK graft was retrieved during the PPV with micro forceps, brought through the pupil and reattached using a SF6 100% bubble). Post operative day one anterior segment OCT showed full graft attachment (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe graft remained well attached post operatively after the SF6 bubble dissipated. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The patient underwent an uncomplicated secondary IOL surgery.\u003c/p\u003e \u003cp\u003ePatient achieved VA of 6/15\u0026thinsp;+\u0026thinsp;2 in the right eye and 6/12\u0026thinsp;+\u0026thinsp;1 in the left eye 2 months post operation on 16 October 2024, with refraction achieving 6/7.5\u0026thinsp;+\u0026thinsp;2 in both eyes, with no improvement with pinhole. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the latest anterior segment OCT. Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the most recent endothelial cell density. Figure\u0026nbsp;6 shows a slit lamp photograph showing a clear cornea and a well centred IOL.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGraft dislocation is the most frequently reported complication after DSAEK due to potential causes such as interface fluid or air, minimal traction provided by smooth recipient interface for donor graft or patient squeezing or eye rubbing.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, in patients with an insufficient barrier between the anterior and posterior chambers of the eye such as defects in the iris or lens capsule, there may be further possibility of posterior dislocation of DSAEK grafts into the vitreous cavity either intra-operatively or post-operatively.\u003c/p\u003e \u003cp\u003eA literature review was done by looking at case reports on posterior dislocation of DSAEK grafts on PubMed with the findings summarised in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eOne of the strongest proposed risk factors for posterior dislocation of DASEK graft is the presence of a decompartmentalized eye affecting graft apposition. The proposed mechanism is that in a decompartmentalized eye, there is a loss of the closed system inside the anterior chamber with little turbulence. Fluid infusion via anterior chamber maintainer would lead to increased turbulence which causes the DSAEK graft to move from its intended position before the air bubble could be injected.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Air movement into the vitreous cavity could prevent sufficient maintenance of tamponade effect.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In our presenting case study, patient was noted to have a subluxed IOL with vitreous noted in the anterior chamber coming around the subluxed IOL, which suggested a breach in the closed system of the anterior chamber. Furthermore, the air bubble was noted to be approximately 70% post operatively but on post operative day one review, the previously subluxed IOL was dislocated and there was no air bubble seen, suggesting the likely migration of the air bubble into the vitreous cavity after the complete dislocation of the IOL, thus affecting the tamponade effect on the graft and causing graft dislocation. Further attempts to re-bubble the graft caused the graft to migrate posteriorly into the vitreous cavity due to the open communication between anterior and posterior segment from the dislocated IOL.\u003c/p\u003e \u003cp\u003eTo reduce the risk of graft dislocation in high-risk patients, putting temporary trans-corneal fixation sutures as part of the primary DSAEK procedure is a promising outlook with little complication and good graft adherence post operation.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Even in graft dislocation, placement of full thickness sutures over the detached area can help with good apposition.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhen posterior graft dislocation arises, the timing for graft retrieval is crucial as there is a correlation between the time taken for graft retrieval and posterior segment complications such as cystoid macular edema or retinal detachment. In general, cases with graft retrieval at time of dislocation or within few days later were associated with no posterior segment complications while those with graft retrieval weeks after dislocation was associated with tractional retinal detachment. There are proposed mechanisms in how posterior dislocated graft can cause retinal detachment. Firstly, a histopathological study of failed DSAEK grafts noted pathological findings of fibrocellular tissue proliferation and epithelial ingrowth, which may predispose to graft adherence to retinal surface. The presence of transplanted foreign ocular tissue in vitreous cavity may evoke a severe inflammatory response which predisposes to early proliferative vitreoretinopathy. Hence, delayed removal of dislocated graft could result in further complications like retinal detachment.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe have presented a case study of an uncommon case of which a posterior dislocation of graft has occurred due the decompartmentalization of the eye following a dislocated IOL. Further research into this area can help to improve on current techniques of DSAEK to tailor towards patients at higher risk of posterior graft detachment as well as targeted management to reduce complications if detachment happens.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePatient Consent\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent to publish this case has been obtained. The patient has given written informed consent for their personal or clinical details along with any identifying images to be published in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgments and Disclosures\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding: No funding or grant support\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConflicts of Interest\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following authors have no financial disclosures: PFS, YTH, JCJ\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthorship\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors attest that they meet the current ICMJE criteria for Authorship\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics Declaration\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials\u0026rsquo; statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its references.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKim SE, Lim SA, Byun YS, Joo CK. 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Posterior dislocation of Descemet stripping automated endothelial keratoplasty graft can lead to retinal detachment. Cornea. 2010;29:1284\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ICO.0b013e3181e84402\u003c/span\u003e\u003cspan address=\"10.1097/ICO.0b013e3181e84402\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Descemet stripping automatic endothelial keratoplasty, posterior Descemet stripping automatic endothelial keratoplasty graft dislocation, subluxed intraocular lens","lastPublishedDoi":"10.21203/rs.3.rs-6432693/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6432693/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: This case report seeks to document an rare case of posterior dislocation of Descemet stripping automated endothelial keratoplasty (DSAEK) graft in a patient with subluxed intraocular lens one day post operation.\u003c/p\u003e\n\u003cp\u003eObservations: A 70-year-old man with a background of subluxed intraocular lens in a non-vitrectomized eye with pseudophakic bullous keratopathy underwent DSAEK. Review on post operative day one noted a posteriorly dislocated graft. Graft repositioning was done on the same day without complications.\u003c/p\u003e\n\u003cp\u003eConclusions and Importance: This case report shows the possibility of DSAEK graft dislocation post operation in a non-vitrectomized eye but with compromised barrier between anterior and posterior chambers of the eye.\u003c/p\u003e","manuscriptTitle":"Posterior dislocation and early retrieval of a Descemet stripping automated endothelial keratoplasty graft","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 06:28:20","doi":"10.21203/rs.3.rs-6432693/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"230eb7aa-1a49-4656-bc9e-3fb8e93fd8b8","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T03:08:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 06:28:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6432693","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6432693","identity":"rs-6432693","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}