Descemet stripping endothelial keratoplasty following simple limbal epithelial transplantation for chemical injury-related endothelial dysfunction: two case reports

Introduction and importance: Ocular chemical injury primarily results in corneal epithelial damage and limbal stem cell deficiency (LSCD), leading to delayed epithelial healing and recurrent epithelial breakdowns. Simple limbal epithelial transplantation (SLET) is the most promising surgical modality for the treatment of unilateral LSCD, helping restore and stabilize the ocular surface. However, in some instances, chemical injury can also result in corneal endothelial damage. This under-recognized entity can mimic SLET failure, leading to delayed or inappropriate management. Case presentation: We describe two patients with chemical injury-induced LSCD who were initially managed with SLET and subsequently developed persistent corneal edema and recurrent epithelial breakdowns. Despite the stable SLET transplants, the recurrent epithelial defects and non-resolving corneal edema raised the suspicion of an underlying endothelial dysfunction. Anterior segment optical coherence tomography (AS-OCT) revealed increased corneal thickness, Descemet membrane irregularity and undulations; and endothelial excrescences. Both patients underwent Descemet stripping automated endothelial keratoplasty (DSAEK). At the final follow-up, both patients demonstrated significant improvement in visual acuity, with a stable epithelial surface and compact cornea. Clinical discussion: Endothelial dysfunction can clinically resemble SLET failure due to overlapping features such as epithelial breakdown, corneal edema, scarring, and vascularization. Anterior segment Optical Coherence Tomography (AS-OCT) is a valuable diagnostic tool when specular microscopy is not feasible, as it can demonstrate features of endothelial dysfunction. Sequential management with initial ocular surface stabilization using SLET followed by endothelial keratoplasty, can achieve favorable outcome in selected cases with minimal underlying corneal scarring. Conclusion: Endothelial dysfunction following chemical injury is frequently overlooked due to compromised visualization of the anterior chamber from the overlying corneal pannus, stromal scarring, and ocular surface inflammation. Early recognition of endothelial involvement is essential. A staged surgical approach, with initial ocular surface reconstruction followed by endothelial keratoplasty, can optimize visual and anatomical outcomes.