70 year old lady underwent DSAEK for endothelial failure.  The surgical procedure was uneventful and nice corneal attachment was achieved with the air bubble.

The next morning she presented with a button detachment. Cornea is very edematous and view into the AC is limited.  Here is a Visante Anterior Segment OCT image below.

But is there any more reason that could explain the button detachment?  With the Visante OCT, one can use the dial to turn the axis of the OCT 360 degrees and as you can see there is no explanation on the 180-0 degree axis, but look at the image below.

Now the axis 85-265 degree clearly shows that on the inferior side of the corneal button, there is a stromal tag that is left behind.  The microkeratome stopped cutting just slightly inside the 9.0 mm corneal trephine used to punch the DSEK button.  The extent of this tag was measured about 2 clock hours by rotating the OCT drum and examining the DSEK Button.

The only remedy for this stromal tag was to return to the operating room, explant the DSEK button, trim the edge using fine scissors and then reinsert the graft.  Successful attachment is achieved as seen the image below.

As one can clearly see the button is nicely attached.  There is a small air bubble trapped in the interface.  The button is slightly tinner where the old stomal tag used to be.

She had excellent recovery despite this minor inconvenience.  She successfully underwent DSEK of her other eye 3 months later.