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Spontaneous corneal clearance after graft detachment in DMEK
Aclaramiento corneal espontáneo tras desprendimiento del injerto en DMEK
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Aunque un injerto DMEK fibrótico (flechas amarillas) se extiende por la cámara anterior del ojo, creando una seudocámara anterior, la córnea es clara, con una agudeza visual de 20/25 (0,8). El ojo es seudofáquico con una lente retropupilar de iris en garra <span class="elsevierStyleItalic">in situ</span> (flechas blancas) (C). Obsérvese que la córnea receptora central, reendotelizada, es clara y de grosor normal, mientras que la córnea periférica, donde está adherido el injerto, muestra edema. Esto puede ser un signo típico de una posición invertida del injerto, ya que el endotelio (en el lado anterior del injerto) es disfuncional en la periferia, mientras que la córnea central se reendoteliza mediante la migración de células endoteliales del injerto al estroma posterior del receptor. La microscopia especular mostró un recuento de células endoteliales de 1.204 células/mm<span class="elsevierStyleSup">2</span> y el coeficiente de variación fue de 77.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Fernández-Vega-Cueto, C. Lisa, K. Vasanthananthan, D. Madrid-Costa, J.F. Alfonso, G.R.J. Melles" "autores" => array:6 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Fernández-Vega-Cueto" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Lisa" ] 2 => array:2 [ "nombre" => "K." "apellidos" => "Vasanthananthan" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Madrid-Costa" ] 4 => array:2 [ "nombre" => "J.F." "apellidos" => "Alfonso" ] 5 => array:2 [ "nombre" => "G.R.J." 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Fundus photograph one month after the start of immunosuppression: bilateral papillary edema with partial macular star in the left eye and scant macular exudates in the right eye. B. Fluorescein angiography: papillary hyperfluorescence with leakage in the arteriovenous time in BE. C. Fundus photograph 7 months after the start of immunosuppression: clear papilla with no macular exudates.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Dorronsoro, S. Bronfen, L. Alconcher, L. Lucarelli" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Dorronsoro" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Bronfen" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Alconcher" ] 3 => array:2 [ "nombre" => "L." 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Caycedo Lozano, W.A. Arias Ortiz, V. Martín, S. Ramírez, C.A. Medina Siervo" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A.R." "apellidos" => "Caycedo Lozano" ] 1 => array:2 [ "nombre" => "W.A." "apellidos" => "Arias Ortiz" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Martín" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Ramírez" ] 4 => array:2 [ "nombre" => "C.A." "apellidos" => "Medina Siervo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669122001174" "doi" => "10.1016/j.oftal.2022.03.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669122001174?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579422001402?idApp=UINPBA00004N" "url" => "/21735794/0000009800000003/v1_202303021216/S2173579422001402/v1_202303021216/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Spontaneous corneal clearance after graft detachment in DMEK" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "170" "paginaFinal" => "174" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L. Fernández-Vega-Cueto, C. Lisa, K. Vasanthananthan, D. Madrid-Costa, J.F. Alfonso, G.R.J. Melles" "autores" => array:6 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Fernández-Vega-Cueto" "email" => array:1 [ 0 => "lfvc@fernandez-vega.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Lisa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "K." "apellidos" => "Vasanthananthan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "D." "apellidos" => "Madrid-Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J.F." "apellidos" => "Alfonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "G.R.J." "apellidos" => "Melles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Instituto Oftalmológico Fernández-Vega, Oviedo, Asturias, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aclaramiento corneal espontáneo tras desprendimiento del injerto en DMEK" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2446 "Ancho" => 2508 "Tamanyo" => 453790 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Slit-lamp (A), specular microscopy (B) and AC-OCT images (C) of the recipient cornea, four months after DMEK surgery. While a fibrotic DMEK graft (yellow arrows) spans the anterior chamber of the eye, creating a pseudo anterior chamber, the cornea is clear, with a visual acuity of 20/25 (0.8). The eye is pseudophakic with a retropupillary iris-claw lens in-situ (white arrows) <span class="elsevierStyleBold">(C).</span> Note that the central, re-endothelialized recipient cornea is clear and of normal thickness, while the peripheral cornea, where the graft is attached, shows oedema. This may be a typical sign of an upside-down graft position since the endothelium (on the anterior side of the graft) is dysfunctional in the periphery, while the central cornea is re-endothelialized through the migration of endothelial cells from the graft onto the recipient posterior stroma. The specular microscopy showed an endothelial cell count 1204 cells/mm<span class="elsevierStyleSup">2</span> and the coefficient of variation was 77.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Descemet membrane endothelial keratoplasty (DMEK) has gained popularity among surgeons due to its good visual and refractive outcomes, faster recovery, and greater patient satisfaction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Theoretically, the key to success is that the graft is perfectly positioned, as it has been classically postulated that corneal clearance does not occur if an endothelial transplant is "detached". However, it has been found on several endothelial keratoplasties corneal clearance with good visual acuity after graft detachment.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> These findings allow postulating that an endothelial migration might occur by the donor, host cells or both. This opens a new frontier to endothelial restoration in which more simplified surgical procedures might be implemented. But also, a question arises on how a graft detachment should be managed.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Here, we present a unique case of a visual recovery after DMEK surgery in a complicated eye that suffered a nearly complete DMEK graft detachment and subsequently an opacification of the detached graft. Both situations were managed without a secondary endothelial keratoplasty.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">In July 2020, a 64-year-old male patient presented himself in our clinic with corneal decompensation in his left eye. His ocular history reported that he suffered from a traumatic cataract in 2007, which was managed by phacoemulsification with retropupillary iris-claw intraocular lens (IOL) implantation (Artisan, Ophtec, The Netherlands). Owing to subluxation, the iris-claw lens was replaced in 2017 by an iris-claw lens positioned in the anterior chamber. In July 2020, we began to manage this patient in our clinic. The patient was diagnosed with Fuchs endothelial dystrophy. Furthermore, corneal decompensation induced by the surgery of the traumatic cataract and anterior-chamber IOL was observed in the left eye. The surgical planning was first to reposition the claw lens behind the iris, and then in a second stage, In Mid-November 2020, a planned DMEK was performed. DMEK graft was prepared following the standardized protocol for the "no-touch" technique. For DMEK surgery, an 8.5 mm epithelial mark was made to outline the planned Descemet's membrane excision area, and a 2.2 main incision was then performed. After scoring the receptor endothelium with an inverted Sinskey hook, a circular portion of Descemet's membrane was stripped from the posterior stroma, creating an 8.5 mm descemetorhexis. Using a Geuder crystal injector (Geuder AG, Germany) filled with balanced saline solution, the Descemet's membrane rolls was inserted into the anterior chamber and then oriented endothelial side down. The anterior chamber was completely filled with air for 60 min, followed by the air-gas (SF6-20%) exchange to pressurize the eye. A final GAS bubble occupying 60% of the anterior chamber was left in the eye overnight. Subsequently, two weeks later, a re-bubbling procedure was performed for subtotal graft detachment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The postoperative course appeared uneventful, and at four of months follow-up, the best-corrected visual acuity had improved to 20/25 (0.8) and the manifest refraction was +2.00–4.00 × 80°. Surprisingly, while the recipient cornea showed complete clearance, a fibrotic DMEK graft was seen across the anterior chamber creating a pseudo-anterior chamber. The endothelial cell count of the clear cornea was 1204 cells/mm<span class="elsevierStyleSup">2</span> and the corneal thickness was 535 μm. This observation agrees with substantial endothelial migration from the graft, host cells or both onto the recipient posterior stroma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4,6–9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although it could not be confirmed by analysis of the surgical video, and although we used intraoperative OCT, the clinical images seemed to indicate that the graft had been positioned upside-down since the peripheral edges of the graft showed an upward scroll (suggesting that the endothelium was on the anterior graft surface because the graft tends to scroll towards the endothelial side) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The reversal corneal clearance pattern also supports the hypothesis that the graft had been positioned upside-down. As the cornea was clear, with a good endothelial cell count, and visual acuity was good, we opted to wait and a close patient's monitoring.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Three months later, the cornea remained clear with an endothelial cell count of about 730 cells/mm<span class="elsevierStyleSup">2</span> and a corneal thickness of 521 μm. However, we observed a significant opacification of the detached graft, and the best-corrected distance visual acuity decreased to 20/63 (0.3) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). We proceeded with the graft removal without performing a second DMEK. Ten months after graft removal, the cornea remained clear with an endothelial cell count of about 510 cells/mm<span class="elsevierStyleSup">2</span> and without significant changes in corneal thickness (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The best-corrected visual acuity was 20/25 (0.8), and the manifest refraction was +2.00–4.50 × 75°. The intraocular pressure was normal at all time points, and no other adverse effects were observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">It has been previously reported that after DMEK, the recipient cornea may remain clear after a graft detachment. Our case report is in line with that finding.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–9</span></a> To explain the spontaneous corneal clearance found in this case report after endothelial graft detachment is valuable to bring two concepts: Descemet stripping only (DSO) and Descemet membrane endothelial transfer (DMET). DSO procedure, which involves not transplanting donor endothelium, might be a valuable alternative to maintain corneal clearance in some cases, probably due to the migration of the endothelium cells from the periphery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> DMET is a surgical concept which has demonstrated that solely the presence of donor endothelial cells on a carrier (a free-floating Descemet roll) inside the anterior chamber is effective in inducing corneal clearance.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> With these two concepts in mind, it has been postulated that spontaneous corneal clearance after endothelial graft detachment could relate to the endothelial regeneration capacity of the donor or recipient or both endothelium.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the mechanism behind this regenerative activity is unclear, it is worthy of note some considerations. Firstly, the disease leading to the endothelial graft seems to influence the capacity for the re-endothelization of the recipient cornea. It has been reported that this mechanism is effective if the surgery’s indication is a Fuchs endothelial dystrophy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Our patient was primarily diagnosed with Fuchs endothelial dystrophy, but it is also important to point out that the surgery of the traumatic cataract and anterior-chamber IOL accelerated the corneal decompensation, and consequently, DMEK surgery was brought forward by a bullous keratopathy. Anitha et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> recently proposed that in patients with bullous keratopathy, the migration of the endothelial cells occurs from partially attached endothelial keratoplasty graft to the host stroma, in contrast to Fuchs endothelial dystrophy, where the endothelial cells would migrate from the periphery to the centre. Perhaps, in our case, both mechanisms concurred. Further efforts are required to understand the re-endothelization mechanism and determine the patient’s profile that may respond positively to this regenerative activity. Secondly, as the remaining ring of recipient endothelium might be involved in the re-endothelization process, a descemetorhexis size of 8.5 mm could affect the mechanisms which involved the recipient endothelium in cells repopulation. Finally, it is important to keep in mind the findings that Birbal et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> reported in 16 eyes who underwent DMET, in which authors concluded that the presence of a nearly completed attached Descemet graft is required to maintain corneal clearance over the long-term.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Graft detachment is the most frequent complication after endothelial keratoplasty. We might have learned two important lessons from our case. First, graft positioning may remain challenging even for experienced DMEK surgeons, especially when the visibility of the anterior chamber during surgery is compromised by corneal oedema and/or other anterior chamber abnormalities (for example after ocular trauma). Second, in cases which suffer a graft detachment may be worthwhile to wait three to six months to evaluate whether a spontaneous visual recovery is achieved<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> since re-intervention may also be associated with increased surgical risks in complicated eyes. Finally, if the detached graft induces visual disturbances, it could be removed and subsequently also to wait three to six months to evaluate whether corneal transparency is maintained without the need to perform a second DMEK.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">Gerrit Melles is a consultant for DORC International/Dutch Ophthalmic USA and SurgiCube International. All other authors have no conflicting relationship to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1856522" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1614330" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1856523" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1614331" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-07-23" "fechaAceptado" => "2022-11-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1614330" "palabras" => array:3 [ 0 => "DMEK" 1 => "Graft detachment" 2 => "Spontaneous corneal clearance" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1614331" "palabras" => array:3 [ 0 => "DMEK" 1 => "Desprendimiento del injerto" 2 => "Aclaramiento corneal espontáneo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descemet Membrane detachment is a potential complication after Descemet Membrane Endothelial Keratoplasty (DMEK). Here, we present a unique case of a DMEK surgery in a complicated eye that suffered a nearly complete DMEK graft detachment and later a graft opacification with a pseudo-anterior chamber. In Mid-November 2020, a planned DMEK was performed in a 64-year-old male patient due to corneal decompensation. Four months after DMEK, a fibrotic DMEK graft was seen across the anterior chamber with a pseudo-anterior chamber; however, the recipient cornea showed complete clearance with an endothelial cell count of about 1204 cells/mm2 and a best-corrected visual acuity of 20/25. Three months later, we observed a significant opacification of the detached graft, and the best-corrected distance visual acuity decreased to 20/63. We proceeded with the graft removal without performing a second DMEK. Ten months after graft removal, the cornea remained clear with an endothelial cell count of about 510 cells/mm<span class="elsevierStyleSup">2</span>, and the best-corrected visual acuity was 20/25.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El desprendimiento de la membrana de Descemet es una complicación potencial tras la queratoplastia endotelial de la membrana de Descemet (DMEK, acrónimo en inglés de after Descemet Membrane Endothelial Keratoplasty). En este artículo, presentamos un caso clínico de una cirugía DMEK en un caso complicado, que sufrió un desprendimiento casi completo del injerto y posteriormente una opacificación de éste y la formación de una pseudo-cámara anterior. En noviembre del 2020, se realizó una cirugía DMEK a un paciente de 64 años debido a una descompensación endotelial. Tres meses después del DMEK, se observó el injerto desprendido y parcialmente adherido, fibrótico en la cámara anterior y formando una pseudo-cámara anterior. Sin embargo, la córnea se mantuvo totalmente transparente con un recuento endotelial de aproximadamente 1204 células/mm<span class="elsevierStyleSup">2</span> y la agudeza visual con corrección fue 20/25. Tres meses más tarde, se objetivó una opacificación significativa del injerto despegado y la agudeza visual disminuyó a 20/63. Procedimos a la extracción del injerto sin realizar una segunda DMEK. Diez meses más tarde, la córnea permaneció transparente con un recuento endotelial de 510 cells/mm<span class="elsevierStyleSup">2</span> y una agudeza visual con la mejor corrección de 20/25.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2446 "Ancho" => 2508 "Tamanyo" => 453790 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Slit-lamp (A), specular microscopy (B) and AC-OCT images (C) of the recipient cornea, four months after DMEK surgery. While a fibrotic DMEK graft (yellow arrows) spans the anterior chamber of the eye, creating a pseudo anterior chamber, the cornea is clear, with a visual acuity of 20/25 (0.8). The eye is pseudophakic with a retropupillary iris-claw lens in-situ (white arrows) <span class="elsevierStyleBold">(C).</span> Note that the central, re-endothelialized recipient cornea is clear and of normal thickness, while the peripheral cornea, where the graft is attached, shows oedema. This may be a typical sign of an upside-down graft position since the endothelium (on the anterior side of the graft) is dysfunctional in the periphery, while the central cornea is re-endothelialized through the migration of endothelial cells from the graft onto the recipient posterior stroma. The specular microscopy showed an endothelial cell count 1204 cells/mm<span class="elsevierStyleSup">2</span> and the coefficient of variation was 77.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1898 "Ancho" => 3083 "Tamanyo" => 395767 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Slit-lamp and AC-OCT images of the recipient cornea six month after DMEK surgery. It could be observed the detached graft. The best corrected distance visual acuity decreased to 20/63 due to a significant opacification of the detached graft. (B) Slit-lamp and AC-OCT images ten months after graft removal.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Queratoplastia en los Estados Unidos: Una revisión de 10 años desde 2005 hasta 2014" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.Y. Park" 1 => "J.K. Lee" 2 => "P.K. Gore" 3 => "C.Y. Lim" 4 => "R.S. 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Dapena" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ICO.0000000000001395" "Revista" => array:6 [ "tituloSerie" => "Cornea" "fecha" => "2018" "volumen" => "37" "paginaInicial" => "141" "paginaFinal" => "144" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28968295" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000009800000003/v1_202303021216/S2173579423000105/v1_202303021216/en/main.assets" "Apartado" => array:4 [ "identificador" => "76120" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Shorts communications" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000009800000003/v1_202303021216/S2173579423000105/v1_202303021216/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579423000105?idApp=UINPBA00004N" ]
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