Transmission Electron Microscopy Corneal Ultrastructure Study in Hematocornea of Corneal Transplant Graft

<b>Background and Clinical Significance</b>: To our knowledge, there is a lack of electron microscopy studies in hematocornea since 1985, and more so for graft hematocornea after deep anterior lamellar keratoplasty (DALK). This study provides an ultrastructural characterization of hematocornea occurring in a DALK graft. Our study presents several limitations: single-case design and lack of control tissue. <b>Case Presentation</b>: The DALK graft with hematocornea was excised and introduced inside of the operating room in glutaraldehyde solution recipient. The graft was quickly cold-transported to light and transmission electron microscopy. Hematocornea in the DALK transplant graft resulted in features of stromal alteration and dysfunctional cellular clean-up response. The collagen lamellae ultrastructure was affected near electron-dense hem deposits. Two cellular aspects were observed: adaptation and degeneration. Electron-dense granules were found in keratocytes, which may exhibit cellular adaptations, such as vacuoles and phagosomes. Macropinocytosis may mechanistically explain ingestion of electron-dense granules, and dysfunctions in the macropinocytosis process may have led to cell degeneration. Cellular degeneration was marked by loss of organelle contour and loss of cellular membrane integrity (burst-cell aspect). Microscopic corneal alteration corresponded to macroscopic total loss of corneal transparency and elasticity. <b>Conclusions</b>: This study described lamellar ultrastructure alterations and dysfunctional cellular response in hematocornea of a DALK corneal transplant graft.