A Novel Approach to Treating Glaucoma and Haab’s Striae with Danielle Trief, MD

At the 2025 New York State Ophthalmological Society (NYSOS) Annual Meeting, Danielle Trief, MD, associate professor at Columbia University Irving Medical Center, attended by Justin Cheong, an MD candidate at Columbia University, presented a surgical video demonstrating the removal of Haab’s striae and subsequent DSEK treatment of a patient with congenital glaucoma and corneal edema.

Patients with congenital glaucoma often face progressive ocular complications due to early surgical interventions, such as trabeculectomy and tube shunt placement. Over time, these procedures can contribute to corneal decompensation, resulting in visual decline and complex surgical considerations.

In the video, Cheong and Trief operated on a man in his 40s who presented with corneal edema and prominent Haab’s striae—breaks in Descemet’s membrane associated with congenital glaucoma. He also had a history of vitrectomy and multiple glaucoma surgeries, contributing to a challenging surgical landscape.

“I think it was interesting because we don’t talk too much about the surgical approach in congenital glaucoma to endothelial keratoplasty; those patients are at risk for corneal decompensation over the years, because their cornea is stretched a bit because of the history of glaucoma,” Trief told HCPLive. “And then a lot of times they’ll have other procedures which reduces their endothelial cell count, and then also the breaks and Haab’s striae can damage the endothelium. So, it poses a surgical challenge, which is what we wanted to address.”

Cheong and Trief deviated from the traditional method of endothelial keratoplasty due to the presence of the striae. Haab’s striae often protrude from the posterior corneal surface, which can interfere with graft adherence. Additionally, given the prior glaucoma surgeries the patient had undergone, DSEK was selected over DMEK for its better chances of adhesion.

During the operation, Trief made the novel decision to peel the Haab’s striae before graft placement. The striae detached cleanly, exposing a smooth corneal surface suitable for graft adhesion. A standard 8 mm DSEK graft was used, despite the patient’s enlarged corneal diameter (approximately 14–15 mm) due to buphthalmos. Trief and Cheong employed 20% SF6 gas to last the full recovery period, which proved effective in maintaining anterior chamber stability and graft position, even in the context of prior vitrectomy and the potential for posterior gas migration.

Trief mentioned key surgical considerations such as graft size selection—opting for a standard 8 mm graft despite the patient’s enlarged cornea—and the use of 20% SF6 gas. Postoperative outcomes were positive, with reduced edema, improved astigmatism, and stable intraocular pressure despite steroid use. The patient’s vision improved from count fingers to 20/80 during the postoperative period.

“We have to keep watch on our patients with congenital glaucoma,” Trief said. “Obviously, the pressure control is paramount, but we should understand that these patients are at risk for corneal decompensation, so if we’re going to do something surgically, we should be careful about the endothelium and our manipulations in the anterior chamber.”

References

1. Trief, D, Cheong, J. DSAEK in a patient with congenital glaucoma, Haab striae, and corneal edema. Presented at the 2025 New York State Ophthalmological Society Annual Meeting, May 16, 2025. New York, NY.