Descemet Membrane Detachment Presenting as Graft Edema After Arcuate Keratotomy in an Eye with Previous Penetrating Keratoplasty-A Case Report.

Introduction and Clinical Significance: Descemet membrane detachment (DMD) is an uncommon but potentially vision-threatening complication of anterior segment surgery. Although immune-mediated graft rejection is a recognized cause of postoperative graft edema following arcuate keratotomy (AK) in eyes with previous penetrating keratoplasty (PKP), structural complications such as DMD may present with similar clinical findings and require fundamentally different management. We report a case of DMD initially misdiagnosed as acute graft rejection following manual AK in a post-PKP eye. Case Presentation: A 47-year-old female with a 20-year history of PKP in the right eye (RE) presented with decreased vision three weeks after undergoing manual AK using a diamond blade to correct high astigmatism. The procedure was complicated by an intraoperative wound leak requiring suturing. Postoperatively, she developed corneal edema and was initially misdiagnosed with acute graft rejection. Despite treatment with topical and systemic corticosteroids, her condition did not improve. Upon referral to our clinic, slit-lamp examination and anterior segment optical coherence tomography (AS-OCT) revealed a near-total, nonplanar DMD. The patient underwent a single air descemetopexy session involving three sequential intracameral air injections, resulting in Descemet membrane apposition and improvement in graft clarity. At 3-month follow-up, visual acuity had improved from hand motion to 20/200, with IOP within normal limits. Longer-term follow-up was unavailable. Conclusions: DMD should be considered as a cause of graft edema after AK in post keratoplasty eyes especially in the presence of complications.