Amy Zhang, Majid Moshirfar, Yousuf M. Khalifa. Deep Vein Thrombosis Following Descemet Stripping Automated Endothelial Keratoplasty. JAMA Ophthalmol. 2013;131(9):1233–1234. doi:10.1001/jamaophthalmol.2013.1720
Venous thromboembolism is the second most common medical complication after surgery.1 The risk factors for development of deep vein thrombosis (DVT) include age, obesity, and diabetes mellitus.1 Deep vein thrombosis associated with ophthalmic surgery, specifically vitreoretinal surgery, has been reported.2
Descemet stripping automated endothelial keratoplasty (DSAEK) offers several advantages over conventional penetrating keratoplasty and has become the standard of care in managing endothelial dysfunction secondary to Fuchs endothelial dystrophy and pseudophakic bullous keratopathy. Descemet stripping automated endothelial keratoplasty involves the injection of an air bubble in the anterior chamber to assist in graft attachment, and patients typically maintain a position for 24 to 36 hours to facilitate graft attachment. Deep vein thrombosis has not been reported as a complication of DSAEK. Herein, we report the development of DVT in 2 patients following DSAEK.
A 76-year-old woman with a history of hypercholesterolemia and hypertension was diagnosed as having Fuchs endothelial dystrophy in both eyes and underwent DSAEK in the left eye with a retrobulbar block and an operative time of 45 minutes. The patient was in face-up position for 1 hour in the postoperative holding area prior to slitlamp examination. At slitlamp examination, the graft remained attached and centered. The air bubble in the anterior chamber cleared the inferior pupillary border. The patient went home and remained in face-up position for 24 hours. She noticed pain in her leg the second night and presented to the emergency department, where she was diagnosed as having DVT via ultrasonography.
A 73-year-old obese woman had a history of transient ischemic attack and diabetes mellitus. At the time of surgery, she was taking metformin hydrochloride, simvastatin, extended-release dipyridamole, diclofenac, and aspirin. All the medications were continued following operation. The patient had a history of Fuchs endothelial dystrophy and aphakia and underwent iris-fixated intraocular lens implantation and DSAEK with an operative time of 75 minutes under topical anesthesia. The patient was in face-up position for 2 hours in the recovery room, and slitlamp examination showed an air bubble that cleared the inferior pupillary margin. On postoperative day 1, the graft was centered with a small peripheral detachment, and a 50% air bubble persisted. She remained in face-up position for 2 additional days, and the peripheral detachment resolved. Five days after surgery, the patient had shortness of breath and was found to have DVT and bilateral pulmonary embolism on evaluation in the emergency department.
Immobilization reduces blood flow, leading to venous stasis that induces venous thromboembolism.2 Our patients were immobilized after surgery; our first patient remained in face-up position postoperatively for 1 day, while our second patient remained in face-up position for 3 days because of a peripheral detachment. More importantly, these patients had several risk factors to induce venous thromboembolism1 (Table). We speculate that preexisting risk factors along with an acquired risk factor, immobilization, in our patients led to development of DVT after DSAEK.
Fuchs endothelial dystrophy correlates with an increased rate of cardiovascular disease.3 Our patients with Fuchs endothelial dystrophy had cerebral vascular disease and hypertension. However, studies in the cell lineage indicate that the vascular and corneal endothelia are derived from mesodermal cells and the neural crest, respectively.4 Thus, additional studies are warranted.
Additional immobilization beyond the typical 24-hour period for management of a partial or full detachment also increases the risk of thromboembolic events. Thromboprophylaxis minimizes surgery-induced venous thromboembolism.1 Based on the American College of Chest Physicians guidelines,1 one may consider administration of anticoagulant agents such as low-molecular-weight heparin for the ophthalmic patients who have risk factors and are undergoing surgery. Mechanical methods of thromboprophylaxis such as intermittent pneumatic compression devices prevent DVT and may be used for patients at high clotting risk or as an adjunct to anticoagulant thromboprophylaxis.1 To prevent the occurrence of DVT in patients undergoing DSAEK who have risk factors for thromboembolic disease, combining the use of an anticoagulant and an intermittent pneumatic compression device intraoperatively and postoperatively may be considered.5
Corresponding Author: Yousuf M. Khalifa, MD, Flaum Eye Institute, University of Rochester, 601 Elmwood Ave, Box 659, Rochester, NY 14642 (firstname.lastname@example.org).
Author Contributions:Study concept and design: All authors.
Acquisition of data: Zhang, Khalifa.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Zhang, Moshirfar.
Administrative, technical, or material support: Zhang, Moshirfar.
Study supervision: Moshirfar, Khalifa.
Conflict of Interest Disclosures: None reported.