Stromal graft rejection after uneventful deep anterior lamellar keratoplasty with a misleading manifestation similar to viral endotheliitis

We describe an unusual and misleading manifestation of stromal graft rejection after uneventful deep anterior lamellar keratoplasty (DALK). A 25-year-old healthy man with advanced keratoconus underwent uneventful DALK. After a few months, developed recurrent graft oedema, acute and diffuse epithelial and stromal oedema, few very fine keratic precipitates (KPs) in the allograft and not seen in the recipient bed, anterior chamber (AC) inflammation with cells and flair, without any vascularization in the graft and recipient bed, and without any infiltration or loosening of the sutures. Polymerase chain reaction (PCR) analysis was performed on an aqueous sample, which was negative for herpes simplex virus (HSV) and cytomegalovirus (CMV). Management with topical and systemic steroids led to complete resolution of the problem. Although there is no endothelial immune reaction after uneventful DALK, stromal graft rejection after DALK can present with the same features as endothelial graft rejection and should be differentiated from other similar demonstrations such as viral induced endotheliitis.