[Penetrating keratoplasty in high-risk children: prevention of graft rejection]

PURPOSE

To evaluate the efficacy of prolonged courses of systemically administered subtherapeutic Metipred and cyclosporine in prevention of graft rejection in high-risk children.

MATERIAL AND METHODS

The study included 27 children at high risk of graft rejection due to re-keratoplasty (n = 8), limbo-keratoplasty for corneal staphyloma (n = 4), or transplantation into vascularized corneal bed (n = 15). All patients were divided into two groups--the study group (n =11) and the control group (n = 16). In order to evaluate the efficacy of two different prevention schemes, the occurrence of graft rejection, rejection crises, and crisis-associated clouding of the transplant was analyzed.

RESULTS

The occurrence of transplant opacity was two times lower in the Metipred-cyclosporine group than in the conventional prevention group. Kaplan-Meier one-year survival of the transplant was 53% in the study group and 27% in the control group. Two-year survival rate difference appeared even more significant--53% and 18% correspondingly.

CONCLUSION

It is clinically shown that subtherapeutic use of Metipred and cyclosporine decreases the occurrence of rejection crises and transplant failure almost by half in high-risk patients as compared with topical corticosteroids; at the same time the side effects of systemic immunosuppression are not substantial. Thus, the suggested prevention scheme allows to perform keratoplasty and expect a clear transplant in children who previously were considered inoperable, i.e. with total vascularized corneal opacity, giant staphylomas, and corneal burns.

[Rhegmatogenous retinal detachment in a patient with previous penetrating keratoplasty (clinical case)]

We present the case of a 54 year old patient diagnosed with rhegmatogenous retinal detachment and perforating keratoplasty. Surgery is recommended and we performed posterior vitrectomy, endolaser, and internal heavy oil tamponade. The post-operative course was favorable.

[Fungal dacryocystitis with cacosmia after penetrating keratoplasty--taxonomy and identification of pathogenic fungi based on DNA sequence analysis]

CASE

A 76-year-old woman with a history of penetrating keratoplasty had cacosmia associated with dacryocystitis. Two species of yeast-like fungi were isolated from the contents of her lacrimal sac. Each cultured fungus had a unique, distinctive odor. Althogh treated with an oral antifungal agent and washing of the nasolacrimal duct, the cacosmia was not improved. The continuous dacryocystitis with cacosmia was treated by dacryocystectomy. Two yeast-like fungi were again isolated from the contents of the lacrimal sac. Pathological examination confirmed a diagnosis of fungal dacryocystitis based on the fungal hyphae observed on the excised lacrimal sac wall. The cacosmia promptly disappeared. The fungi isolated from the contents of lacrimal sac were identified by DNA sequencing as Wickerhamomyces anamalus (Pichia anomala-Candida pelliculosa) and Galactomyces geotrichum (Geotrichum candidum).

CONCLUSION

The cause of cacosmia in the present case was fungal dacryocystitis. Antibiotic eye drops and steroid eye drops for the treatment of penetrating keratoplasty can cause atypical fungal presentation in the inconsistently treated lacrimal system and can induce dacryocystitis. Careful usage and consideration is necessary in the long-term use of antibiotics and steroids following corneal transplantation.

Quantifying changes in corneal neovascularization using fluorescein and indocyanine green angiography

PURPOSE

To quantify changes in corneal neovascularization in patients with active keratitis after treatment using color imaging, fluorescein angiography (FA), and indocyanine green angiography (ICGA).

DESIGN

Prospective, interventional case series.

METHODS

Twelve consecutive patients were studied. A comparison of corneal neovascularization parameters was undertaken before and after resolution of the keratitis. A slit-lamp digital camera acquired images of the neovascularization using color imaging, FA, and ICGA. The best-quality images were selected using a grading system, and the neovascular regions of interest were analyzed using automated in-house software. The parameters of analysis were vessel area, diameter, tortuosity, and FA dye leakage.

RESULTS

There was a significant reduction in the area of neovascularization after treatment on color imaging (0.78 mm(2); P < .05), FA (2.33 mm(2); P < .01), and ICGA (2.07 mm(2); P < .01). There was also a significant reduction in mean vessel diameter across the region of interest for each patient, more marked on FA (42.74 to 32.52 μm; P < .01) and ICGA (44.77 to 33.29 μm; P < .01) than on color imaging (29.10 to 25.17 μm; P < .01). A significant change in vessel tortuosity was not observed. There was a significant increase in FA dye leakage time (12.41 seconds; P < .05) after treatment.

CONCLUSIONS

We demonstrate application of an objective method for analyzing changes in corneal neovascularization. The excellent vessel delineation with ICGA even in the presence of stromal scars makes it an ideal agent for measurement of vessel parameters. FA is useful at detecting vessel leakage, and the time to leakage provides a possible measure of vessel staging.

Rabies in a blind patient: confusion after corneal transplantation

Two blind persons received corneal transplants from a single donor who showed no signs of rabies before he died. One of the recipients, a young girl, died 16 days later of rabies and the other recipient survived. We discuss the possible mode of transmission of rabies to the first recipient and the management of the second recipient.

[Functional results of contact lens correction and penetrating keratoplasty in keratoconus. Report 2. Wavefront analysis]

Comparative analysis of optic aberrations in contact lens correction and after penetrating keratoplasty (PKP) in keratoconus are presented. 117 patients (219 eyes) with stage I-IV keratoconus, wearing rigid gas-permeable contact lenses (RPCL), and 60 patients (64 eyes) after PKP were examined using OPD Scan (NIDEK, Japan) to assess aberration characteristics. Total optic aberrations and higher-order aberrations of ocular and corneal wavefront were significantly increased after PKP compared to those in patients with I-III stage keratoconus wearing RGCL. Astigmatic aberrations after surgery are increased compared to that in patients wearing RGCL regardless of keratoconus stage. Generally, according to objective aberrometry efficacy of PKP is similar to that of contact lens correction in IV stage keratoconus.

1-year follow-up study of endothelial cell density loss after penetrating keratoplasty

High endothelial cell density (ECD) is essential for the corneal graft clarity. We evaluated ECD loss in 120 eyes that underwent penetrating keratoplasty (PK) in Eye Clinic Svjetlost in a one year follow up period. Patients were divided into 3 groups of high (N = 35), intermediate (N = 31) and low risk (N = 54) for graft failure. Postoperative central endothelial density, coefficient of variation in cell area (polymegathism), percentage of hexagonal cells (pleomorphism) in comparison to preoperative donor cell measurements were determined in the following postoperative time-points of 1, 2, 3, 6, 9 and 12 months. There were no significant differences in the preoperative ECD values, storage time, donor age or surgical procedures between groups. Throughout all time points intermediate group had the greatest statistically significant ECD loss as compared to high and low risk groups. There were no significant differences between high and low risk group. After 12 month post PK, intermediate risk group had 28.38% ECD loss as compared to 24.07% in high and 23.03% ECD loss in low risk group. Coefficient of variation in cell area (CV) was for high risk group 0.34, intermediate 0.40 and low risk 0.31 which was not significantly different between groups. Percentage of plemorphism in high risk was 54%, intermediate 58% and in low risk 48% which was significantly different as compared to other two groups. Our study showed that corneal pathology is among others, very important prognostic factor for ECD after PK. However, longer follow up period is needed.

Influence of suture regularity on corneal astigmatism after penetrating keratoplasty

PURPOSE

To investigate whether suture regularity affects corneal astigmatism after keratoplasty.

METHODS

Twenty-one patients undergoing penetrating keratoplasty for various corneal diseases were included in the study. The grafts were sutured in place using a single-running Nylon 10-0 suture, taking 24 bites. Immediately after surgery, standard calibrated images of the grafted eye were captured and stored. Using a dedicated image analysis programme, stitches and needle points were identified, and a number of suture regularity variables were calculated. Corneal topographic images were obtained before suture removal (12 months after surgery) and 3 months after suture removal (18 months after surgery). Topographic measures of astigmatism [surface regularity (SRI), surface asymmetry index (SAI) and simulated keratometric astigmatism] were calculated and correlated with the computed suture regularity variables.

RESULTS

The average stitch length was 3.04 ± 0.28 mm and the distance between the outer needle points was 2.53 ± 0.09 mm. The SRI was 1.26 ± 0.36 and the SAI was 1.59 ± 0.67 after 12 months; these decreased to 1.03 ± 0.48 and 0.92 ± 0.46 after 18 months, respectively. Corneal astigmatism was 6.38 ± 2.99 and 5.87 ± 3.13 dioptres after 12 and 18 months, respectively. Suture regularity did not affect SAI, SRI or corneal astigmatism significantly 12 months after surgery. Eighteen months after surgery (3 months after suture removal), the standard deviation on the original stitch length was found to significantly increase corneal astigmatism. In addition, the size of the counter-clockwise angle between stitch and graft radian was correlated significantly with a lower SRI.

CONCLUSION

The origin of corneal astigmatism after penetrating keratoplasty is multifaceted. Regular stitch length and stitch advancement on the surface appears to improve the optical quality of the graft after suture removal. Factors such as stitch depth, suture tension and variations in wound construction might also be important predictors of corneal astigmatism after penetrating keratoplasty.

Graft rejection and graft failure after anterior lamellar versus penetrating keratoplasty

PURPOSE

To compare anterior lamellar keratoplasty (ALK) with the reference surgical technique (penetrating keratoplasty [PK]) for risk of rejection.

DESIGN

Retrospective, comparative case series.

METHODS

setting: Institutional. patients: One hundred forty-nine consecutive ALK procedures (ALK group) and 149 matched PK procedures (PK group) performed for optical indication in eyes with corneal diseases not involving the corneal endothelium (ie, keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma). main outcome measures: Three-year graft survival and cumulative incidence of rejection episodes.

RESULTS

The 3-year overall graft survival was 98.3% in the ALK group and 94.3% in the PK group (P = .03). The 3-year cumulative incidence of irreversible rejection was 0.0% in the ALK group and 5.2% in the PK group (P = .02). The 3-year cumulative incidence of rejection episodes was 10.0% in the ALK group and 23.2% in the PK group (P = .01). The average graft-to-rejection episode time was 21.6 ± 22.0 months in the PK group and 19.4 ± 12.7 months in the ALK group (P = .76).

CONCLUSIONS

ALK techniques dramatically decrease the risk of irreversible endothelial and stromal rejection after corneal transplantation. Immune-mediated rejection episodes are observed after ALK, but its lower graft failure rate compared with PK is at least partly the result of the absence of endothelial rejection. In addition, the incidence of rejection episodes after ALK was 50% less than that observed after PK.

Comparison of astigmatic keratotomy results in deep anterior lamellar keratoplasty and penetrating keratoplasty in keratoconus

PURPOSE

To compare astigmatic keratotomy (AK) outcomes in high astigmatism after deep anterior lamellar keratoplasty (DALK) and after penetrating keratoplasty (PK) in keratoconus patients.

DESIGN

Prospective, comparative, interventional case series.

METHODS

This study comprised 20 eyes that underwent DALK and 24 eyes that underwent PK. After suture removal, all eyes had more than 5 diopters (D) of astigmatism and underwent standard manual 1-pair, 90-degree, and 90% corneal thickness AK incisions. The main outcome measures included preoperative and postoperative manifest refraction, uncorrected visual acuity, best spectacle-corrected visual acuity, surgically induced astigmatism, Orbscan II (Bausch & Lomb) corneal topography results, keratometric astigmatism, and complications.

RESULTS

All eyes completed 6 months of follow-up. The overcorrection rate was 35% and 41.6% in the DALK and PK groups, respectively (P=.75). At 6 months after AK, logarithm of the minimal angle of resolution uncorrected visual acuity improved from 0.88 ± 0.20 to 0.54 ± 0.26 and from 1.0 ± 0.34 to 0.53 ± 0.26 in the DALK and PK groups, respectively (P=.01 to P<.01). Best spectacle-corrected visual acuity improved from 0.16 ± 0.09 to 0.13 ± 0.08 and from 0.16 ± 0.12 to 0.11 ± 0.08 in the DALK and PK groups, respectively (P=.13 to P=.01). The mean refractive cylinder was decreased 2.74 ± 1.44 D in the DALK group and 3.18 ± 2.96 D in the PK group (P=.35). Surgically induced astigmatism was 6.10 ± 3.27 D in the DALK group and 7.15 ± 2.98 D in the PK group (P=.36).

CONCLUSIONS

The manual AK for the treatment of postkeratoplasty astigmatism after DALK and PK in keratoconus patients is a safe and effective surgical procedure, allowing similar refractive cylinder reduction and improvement in uncorrected visual acuity and best spectacle-corrected visual acuity.

Endophthalmitis by Pseudomonas aeruginosa. after penetrating keratoplasty, case report with an epidemiological investigation

INTRODUCTION

An endophthalmitis following penetrating keratoplasty by Pseudomonas aeruginosa is a devasting case with very poor visual outcomes.

OBJECTIVE

To determine the origin of an infection after a penetrating keratoplasty.

MATERIALS AND METHODS

After an endophthalmitis an epidemiological study was undertaken with the approval of the ethics committee and support of a medical team comprised of an epidemiologist, infectologist, bacteriologist and ophthalmologists specializing in cornea. Factors that may have contributed to the risk of infection were assessed, for example, the processing and preservation of the cornea in the moment of the extraction, the characteristics of the donor, recipient and infecting bacterium, as well as the details pertaining to the surgical operation.

RESULTS

No risks factors were found in the institution, in the eye bank facilities, in the donor or in the receptor. However, sterile technique could not be guaranteed in the morgue where the corneal extraction occurred, and other isolated cases of endophthalmitis post-keratoplasty had been documented involving tissues from the same morgue that had been processed by two eye banks in the same city. Characteristics of the multi-resistant Pseudomonas sp. demonstrated its origin from a hospital environment due to its previous exposure to a variety of antibiotics.

CONCLUSIONS

Corneal extraction site must guarantee an antiseptic preparation and aseptic tissue donor recuperation; although in this study it was not feasible to accurately establish the infection source, all of the findings led to suspect a possible contamination at the morgue.

Persistent epithelial defect after penetrating keratoplasty caused by adenoviral infectious keratitis

A causal role of herpes simplex infection in persistent epithelial defect following penetrating keratoplasty (PKP) has been documented in the past. Instead, not much information is available on the role of adenovirus infection in delayed epithelization following PKP. Here, we describe a case of persistent epithelial defect due to adenoviral infection keratitis confirmed by PCR analysis. Adenovirus keratitis can be an unusual cause of delayed epithelization after PKP.

[Corneal ulcer with hypopion in a patient with perforant keratoplasty]

After corneal transplantation, the patients' problems are far from being definitively resolved. The transplant pathology requires an attentive follow-up, as there is always a danger of corneal graft failure. We present here the case of young patient who had a corneal transplantation after an eye injury and who has developed a corneal ulcer on the grafted cornea, with subsequent risk of graft failure and consequent loss of the eye.

The outcome of corneal transplantation versus indications in a tertiary eye care center in Ethiopia

BACKGROUND

The outcome of PKP depends on several factors, mainly on its indications. Understanding the causes of graft failure may help to reduce the risk of failure. This study was designed to analyze and compare the long term outcomes of PKP for the different indications in our set up.

OBJECTIVE

To assess the graft survival and visual outcome of full thickness corneal transplantation with respect to its indications at a tertiary eye care center in Ethiopia.

METHODS

A retrospective analysis was done on all patients who underwent full thickness corneal transplantation at Menilik II hospital during a 5 year period from January 1st, 2001 to December 30. 2006.

RESULTS

111 cases completed their two years of follow-up at the time of study. The most common indication for penetrating keratoplasty (PKP) was post-inflammatory corneal opacity in 54/111 (48.6%) followed by keratoconus in 25 (22.5%) cases. The over all graft survival rate at two years was 76.6%. Keratoconus having the most favorable survival rate of 92%, to be followed by corneal dystrophy, (81.8%). Pre-operative corneal vascularization and anterior adherent leukoma corneas (AALK) have been shown to be significantly associated with higher risk of graft failure (p < 0.05).

CONCLUSION

These results show that PKP has a very good outcome for keratoconus and corneal dystrophies. Corneal vascularization and AALK is associated with higher incidence of graft failure. Preoperative patient selection and ensuring conmpliance is shown to be essential.

Long-term safety and visual outcomes of transscleral sutured posterior chamber IOLs and penetrating keratoplasty combined with transscleral sutured posterior chamber IOLs

PURPOSE

To evaluate the outcomes of consecutive patients who underwent transscleral sutured posterior chamber intraocular lens (TS PCIOL) implantation as well as patients who had combined penetrating keratoplasty (PK) and TS PCIOL.

METHODS

Data from all patients who had sutured PCIOL insertion performed by the same surgeon (V.S.N.) between January 2003 and June 2007 were compiled and analyzed.

RESULTS

Group 1 consisted of 69 eyes of 67 patients who had TS PCIOL only. Mean age was 65.1 years, and mean follow-up was 14.25 months. Mean best spectacle-corrected visual acuity (BSCVA) was 20/80 preoperatively and 20/40 postoperatively. Group 2 consisted of 38 eyes of 37 patients who had combined PK and TS PCIOL. Mean age was 70.21 years, and mean follow-up was 14.29 months. Mean BSCVA was <20/250 preoperatively and between 20/70 and 20/80 postoperatively. In both groups, there were no reported cases of choroidal hemorrhage or hyphema. There was one case (0.9%) of suture erosion (group 1). There were no redislocations, lens tilting, suture breakage, or graft rejections. Postoperative complications included uveitis in 1 eye (0.9%), glaucoma in 5 (4.7%), cystoid macular edema in 6 (5.6%), and retinal detachment in 2 (1.9%).

CONCLUSIONS

The TS PCIOL procedure, as done by the ab externo method, is safe and effective. It has few intraoperative or postoperative complications, and it improves visual acuity in patients requiring either TS PCIOL alone or combined PK and TS PCIOL. Ultimately, in considering TS PCIOL, patient selection, surgical method, and the surgeon's comfort with the technique must be weighed.

Diode Laser Transscleral Cyclophotocoagulation for the Treatment of Refractory Glaucoma After Penetrating Keratoplasty

PURPOSE

To evaluate the effect and safety of diode laser transscleral cyclophotocoagulation (TSCPC) in eyes with refractory glaucoma after penetrating keratoplasty (PK).

METHODS

Diode laser TSCPC was performed on 32 eyes of 32 patients with secondary glaucoma after penetrating keratoplasty. The mean follow-up period was 11.4 +/- 3.8 months (range, 6-20 months). The intraocular pressure (IOP), number of glaucoma medications, graft status, side effects, and complications of the procedure were all recorded during the follow-up period. The treatment was considered successful if after one cyclodiode treatment the IOP could be reduced to or below 22 mmHg with or without medication. The success rate of the diode laser treatment was analyzed by the Kaplan-Meier survival analysis method during the 6th and 12th months of the follow-up period and the end of the study. The decrease in drug requirement after laser treatment was analyzed by the Wilcoxon nonparametric test. Statistical significance was set at p < 0.05.

RESULTS

During the follow-up period, diode laser TSCPC reduced the IOP significantly. Our cumulative success rate was 56% at the end of the study. Cyclodiode treatment resulted in an IOP less than 22 mmHg in 97% of the eyes on the 6th month and 72% of the eyes on the 12th month with or without medication. The total retreatment rate of the study was 44%. More than one treatment was necessary, 8 times in the 1st month, 9 times in the 3rd month, 5 times in the 6th month and 3 times in the 12th month. The average number of antiglaucomatous drugs used was 2.8 before surgery and 1.2 after the 12th month follow-up period (p < 0.05). No eyes with graft failure after treatment were present. Visual acuity improved (> 2 Snellen lines of acuity) in two eyes and remained the same in the others. No serious side effects such as phthisis bulbi or hypotonia were observed.

CONCLUSIONS

Diode laser TSCPC appears to be a safe and effective procedure for the treatment of uncontrolled glaucoma secondary to penetrating keratoplasty.

Corneal wavefront errors 24 months after deep lamellar endothelial keratoplasty and penetrating keratoplasty

PURPOSE

To evaluate high-order aberrations (HOA) induced by the anterior corneal surface after deep lamellar endothelial keratoplasty (DLEK) and penetrating keratoplasty (PK).

DESIGN

Prospective, randomized clinical trial.

METHODS

Twenty-eight eyes of 25 patients with corneal edema resulting from Fuchs dystrophy underwent DLEK with a 9- to 10-mm incision (n = 13) or PK with double-running sutures (n = 15) at the Cornea Service, Mayo Clinic Department of Ophthalmology, Rochester, Minnesota. The main outcome measures were HOA from the anterior corneal surface calculated from corneal topography and decomposed into Zernike polynomials to the sixth order, high- and low-contrast visual acuity (VA), and contrast sensitivity. Variables after surgery were compared with those before surgery and between treatments by using generalized estimating equation models with Bonferroni adjustment.

RESULTS

Total HOA through 24 months (0.48 +/- 0.15 microm) after DLEK was similar to total aberration before surgery (0.44 +/- 0.23 microm; P = .10). After PK, total HOA remained elevated through 24 months (1.68 +/- 0.58 microm) compared with that before surgery (0.49 +/- 0.27 microm; P < .005) and compared with that after DLEK (P < .006). At 24 months after PK, corneas with sutures removed had greater total HOAs than corneas with sutures intact (1.90 +/- 0.52 microm vs 1.18 +/- 0.33 microm; P = .001). High- and low-contrast VA and contrast sensitivity at 24 months after PK did not correlate with any HOA.

CONCLUSIONS

HOAs from the anterior corneal surface were higher after PK compared with after DLEK but did not correlate with visual function after PK.

Descemet's stripping automated endothelial keratoplasty and penetrating keratoplasty for Fuchs' endothelial dystrophy

PURPOSE

To compare the outcome of Descemet's stripping endothelial keratoplasty (DSAEK) to that of penetrating keratoplasty (PK) in patients with Fuchs' endothelial dystrophy.

METHODS

The first 20 patients who underwent DSAEK at the Department of Ophthalmology, Aarhus University Hospital were compared to 20 patients treated with classic PK. Best-corrected visual acuity, subjective spectacle refraction and corneal thickness were registered before surgery and 1, 3, 6 and 12 months after DSAEK surgery; they were also measured before surgery and 12 months and 2-3 years after PK. Endothelial cell density was measured 12 months after surgery in both groups.

RESULTS

Two primary graft failures were observed in the DSAEK group; no failures were seen in the PK group. Best spectacle-corrected visual acuity (BSCVA) at 12 months after surgery was significantly better in the DSAEK group (0.56 +/- 0.04) than in the PK group (0.33 +/- 0.06). At this time, 70% of the DSAEK-treated eyes but only 25% of PK-treated eyes had obtained a BSCVA of 0.5 or better. Two to three years after surgery, BSCVA was 0.5 or better in 55% of PK-treated eyes. Refractive ametropia and astigmatism were significantly smaller in DSAEK-treated eyes than in PK-treated eyes, even after suture removal and arcuate keratotomy. Endothelial cell density (cells/mm2) after 1 year was lower in DSAEK-treated (1.338 +/- 113) than in PK-treated eyes (1.610 +/- 124), but the difference was not statistically significant.

CONCLUSION

DSAEK seems to be superior to PK in treating Fuchs' endothelial keratoplasty, although primary graft failure may be more common. Visual recovery is faster, and major ametropia and astigmatism is not induced. Long-term follow-up studies are essential to assess whether this conclusion also holds true more than 1 year after surgery.