CASE REPORT Persistent Corneal Opacity After Descemet Stripping Automated Endothelial Keratoplasty Suggesting Inert Material Deposits Into the Interface Priyanka Chhadva, BS,* Florence Cabot, MD,*† Noel Ziebarth, PhD,‡ George D. Kymionis, MD, PhD,§ and Sonia H. Yoo, MD*† Purpose: To report a case of interface deposits after Descemet stripping automated endothelial keratoplasty (DSAEK) imaged by means of an electron microscope. Methods: An 88-year-old man was referred with a history of corneal edema resulting from pseudophakic bullous keratopathy. A DSAEK was performed on his left eye without complications; however, the follow-up examination revealed a well-attached graft with persistent interface opacities at the donor–recipient interface. The DSAEK was repeated in this eye 1 year after the first surgery because of these corneal opacities that interfered with his vision. Results: In the immediate postoperative period, the patient had adequate visual acuity with intact graft placement and a clear interface. Pathology and electron microscope analysis were performed on the removed endothelial graft, which revealed diffuse particles on the stromal surface of the endothelial graft. Conclusions: A repeated DSAEK procedure sufficiently removed this patient’s corneal opacities and improved the visual acuity. The opacity is believed to have occurred because of residual viscoelastic material, which was used to maintain anterior chamber volume during surgery. This solution must be thoroughly removed to avoid similar complications. Key Words: Descemet stripping automated endothelial keratoplasty, corneal interface opacity, electron microscope imaging (Cornea 2013;32:1512–1513) H istorically, the treatment for pseudophakic bullous kerat- opathy was penetrating keratoplasty; however, Descemet stripping automated endothelial keratoplasty (DSAEK) is now routinely performed. 1 The most common early complications include graft detachment, rejection, dislocation of the posterior corneal graft, and pupillary block. 2 Deposits within the inter- face have previously been described in the literature as DSAEK complications, but the etiology of these deposits is unknown. 3 We describe a case in which electron microscopy helps image inert material deposits within the interface, which is an uncommon complication that occurs after a DSAEK and led to regraft in this patient. REPORT OF A CASE An 88-year-old man was referred to our institute for corneal evaluation. His medical history consisted of bilateral cataract surgery that was performed 11 years ago, glaucoma for which he underwent 2 trabeculectomy procedures in his right eye and 1 in his left eye, and dry age-related macular degeneration. Because of advanced glaucoma, this patient had poor vision in the right eye (counting fingers), but complained of decreasing vision in the left eye. His vision was 20/200 in the left eye, and a slitlamp examination revealed corneal edema in both eyes as a result of pseudophakic bullous keratopathy. A DSAEK was subsequently performed on his left eye without complications. The graft was prepared by the Florida Lions Eye Bank before surgery via a microkeratome FIGURE 1. Slitlamp photograph of the left eye 1 year after the first DSAEK. Diffuse interface opacities remained stable. Received for publication April 12, 2013; revision received June 19, 2013; accepted June 20, 2013. From the *University of Miami, Miller School of Medicine, Miami, FL; †Bascom Palmer Eye Institute, Miami, FL; ‡Biomedical Atomic Force Microscopy Laboratory, Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, FL; and §University of Crete, Crete, Greece. The authors have no funding or conflicts of interest to disclose. Reprints: Sonia H. Yoo, Bascom Palmer Eye Institute, 900 NW, 17th St, Miami, FL, 33126 (e-mail: syoo@med.miami.edu). Copyright © 2013 by Lippincott Williams & Wilkins 1512 | www.corneajrnl.com Cornea  Volume 32, Number 11, November 2013