Stromal Graft Rejection after Uneventful Deep Anterior Lamellar Keratoplasty that Mimics Endothelial Rejection

To describe the clinical features, management, and visual outcome in a case of stromal rejection with a rare and unusual presentation after deep anterior lamellar keratoplasty (DALK).
Case report: A 25-year-old healthy man with advanced keratoconus underwent DALK using the standard big bubble technique in his right eye. Five months after surgery, the patient involved in red eye, decreased vision, acute epithelial edema, acute and diffuse stromal edema, fine diffuse keratic precipitates (KPs) in the graft location and AC (anterior chamber) inflammation with cells and flair without any vascularization in the graft and recipient bed, and any infiltration or loosening of the sutures. Management with topical and systemic steroids, and topical antibiotic lead to complete resolution of stromal edema, KPs and AC inflammation. Nine months after the first episode, the patient was referred due to the same clinical presentation and similar findings on examination. Recurrence was treated successfully with the same prior medications and clear graft was achieved.
Although there is no endothelial immune reaction after DALK for keratoconus, stromal graft rejection after DALK can be presented with the same features as endothelial graft rejection and should be differentiated from herpes simplex virus (HSV) keratouveitis.