Large corneal grafts can be successful

Large-Diameter Penetrating Keratoplasties are Mostly Due to Very Severe Infectious Keratitis and Cannot Always Prevent Secondary Enucleation

PURPOSE

To report the indications and outcomes of penetrating keratoplasties with a graft diameter > 8.5 mm in severe corneal diseases at the Department of Ophthalmology at Saarland University Medical Centre.

STUDY DESIGN

Retrospective (6 years), descriptive, and observational.

METHODS

Thirty-five large-diameter penetrating keratoplasties (LDPKPs) in 27 patients (mean age, 62 ± 22 years) were performed from March 2010 to December 2016. The indication for surgery, number of previous corneal transplantations, best-corrected visual acuity (BCVA) before surgery, intraocular pressure, graft status, and BCVA at last follow-up were recorded.

RESULTS

Infectious keratitis represented 83% of the indications (of those, 45% fungal). The mean corneal graft diameter was 10.8 ± 1.7 (min 8.75, max 15.0) mm. Twenty-three eyes (65% absolute) had at least one previous penetrating keratoplasty (mean graft size, 9.2 ± 1.6 mm). The mean pre-surgery BCVA was 1.96 ± 0.23 logMAR. With a mean follow-up period of 20.2 ± 13.4 months, the mean BCVA was 1.57 ± 0.57 logMAR at last follow-up. Overall, 12 grafts (35%) remained clear until the last follow-up, and in 23 grafts (65%), the primary disease recurred, or corneal decompensation developed. Up to the last follow-up, 6 eyes (17%) had to be enucleated.

CONCLUSIONS

In complex cases of infectious keratitis requiring a LDPKP to remove the complete pathology and preserve eye integrity, the visual outcomes are generally expected to be poor, not only because of the well-known risks of LDPKP but also because of the consequences of the infectious disease itself. This knowledge is important for adequate counselling of the patient preoperatively.

Outcome of Sclerokeratoplasty in Devastating Sclerocorneal Infections

Purpose:

To assess the achievement of anatomical integrity after primary tectonic sclerokeratoplasty procedure and outcome after subsequent secondary procedures to manage devastating corneoscleral infection threatening the structural integrity of the eyeball.

Methods:

This prospective interventional study comprised 60 patients with severe devastating corneoscleral pathology of infective origin with varying degrees of scleral involvement who underwent tectonic sclerokeratoplasty. They were grouped into three groups according to the involvement of scleral quadrants, i.e., Group A with only one quadrant, Group B with two quadrants, and Group C with more than two quadrants. The demographics, clinical features, microbiological status, postoperative complications, need for secondary procedures, and tectonic outcome in terms of anatomical success were analyzed in all three groups during follow-up between 2 and 5 years.

Results:

The donor graft size in Groups A, B, and C was 9.5–10.5, 11–12, and 12.5–14 mm, respectively. Globe integrity after primary procedure was noted in all patients of Group A, 76% of Group B, and 38% of Group C. Reinfection was observed in 19 cases of Groups B and C, from which 5 Group C patients were eviscerated and 14 underwent regrafting. Postoperative complications (suture related, rejection, graft failure, and secondary glaucoma) were encountered more frequently in Group C patients. Secondary procedures (cataract/posterior segment surgery, secondary intraocular lens, and trabeculectomy) were required more in Groups B and C. After regrafting, 7 eyes were salvaged and 7 (3 in Group B and 4 in Group C) resulted in phthisis bulbi. Thus, tectonic outcome was achieved in 80% of cases.

Conclusions:

Sclerokeratoplasty is an effective tectonic treatment for restoring the globe anatomy in severe corneoscleral infection. Outcome depends on involvement of scleral quadrants, graft size, and severity of disease. Subsequent regrafting procedures are required to overcome reinfection of the primary graft.

Clinical features of immune rejection after corneoscleral transplantation

PURPOSE

To summarize the clinical features of immune rejection after corneoscleral transplantation.

DESIGN

A retrospective, noncomparative, observational case series.

METHODS

Patients who received corneoscleral transplantation because of whole corneal ulcer or corneal perforation at Shandong Eye Institute from July 1, 2003 through July 31, 2005 were included. Fourteen patients (14 eyes) with immune rejection but not recurrence or other complications were reviewed, including ocular vision, rejection onset time, symptoms, and characteristics.

RESULTS

The average rejection time in the 14 eyes was 35 days. The rejection arose rapidly, and the mean best-corrected visual acuity decreased to counting fingers or hand movements. Circular limbal congestion and edema developed with circuitous and dilatational vessels. Whole graft edema and Descemet membrane folds were present, but no epithelial rejection line, endothelial rejection line, or keratic precipitate were observed. The average intraocular pressure (IOP) dropped from 13.6 mm Hg to 7.4 mm Hg. Seven eyes had shallow anterior chambers (AC). Retinal and choroidal edema was observed in five eyes.

CONCLUSIONS

The clinical features of immune rejection after corneoscleral transplantation include rapid onset of rejection, vision decrease, circular limbal congestion and edema with circuitous and dilatational vessels, whole graft edema and shallow AC, low IOP, and no rejection line or keratic precipitate.

The future of lamellar keratoplasty

New surgical techniques in lamellar keratoplasty, including phototherapeutic keratectomy, automated lamellar keratectomy, plano-epikeratoplasty, deep anterior lamellar keratoplasty, combined amniotic membrane and limbal transplantation, large-diameter corneoscleral lamellar keratoplasty, and posterior lamellar keratoplasty, have recently become available. These procedures broaden the array of treatments for corneal disorders and may be used as alternatives to penetrating keratoplasty.

Corneoscleral transplantation for end stage corneal disease

AIM

To describe the prognosis and complications of corneoscleral transplantation in the management of end stage eye disease.

METHODS

A case series is presented of 23 patients who have undergone corneoscleral transplantation (> or = 11 mm). Patients were examined for visual acuity, intraocular pressure, recurrence of disease process, epithelialisation of the graft, signs of rejection, and other potential complications.

RESULTS

14 patients retained their eye, with six maintaining a clear graft. Vision ranged from 6/30 to no perception of light. 13 patients developed glaucoma (range 25-69 mm Hg), with six patients requiring surgical intervention. 12 patients required tarsorrhaphy to promote epithelialisation. Only two grafts resulted in typical rejection.

CONCLUSIONS

The technique of corneoscleral transplantation can salvage otherwise end stage eye disease, but the results are poor with respect to maintenance of vision. These patients need careful follow up because of potential complications of glaucoma, epithelial defects, rejection, and recurrence of disease.

Prognosis for keratoplasty in Acanthamoeba keratitis

STUDY

Penetrating keratoplasty (PK) was undertaken between 1985-1991 at Moorfields Eye Hospital in 13 eyes (19 PKs) of 11 patients who developed Acanthamoeba keratitis. Infection was ultimately controlled in all cases. Retrospective analysis was undertaken to establish risk factors for PK. Six eyes were quiet and 7 had uncontrolled infection at the time of keratoplasty. The outcome for these was compared.

COMPLICATIONS

Complications included cataract in 50% of quiet eyes and 100% of inflamed eyes. Intumescent cataract resulted in glaucoma requiring drainage surgery in 4 eyes. Graft rejection episodes occurred in 50% of quiet eyes, but were treated aggressively and did not cause graft failure.

RESULTS

Graft survival was excellent for quiet eyes, but was compromised by recurrent infection in inflamed eyes and 6 patients were regrafted. Survival compared poorly with grafting for active herpetic or bacterial keratitis, indicating that early diagnosis and treatment are essential for adequate control of this disease.

The role of penetrating keratoplasty in the management of microbial keratitis

Penetrating keratoplasty was performed as an emergency procedure in 52 eyes which had perforated from acute microbial keratitis and in a further 11 where perforation had not yet occurred. The results are compared with those of keratoplasty in 33 non-infected perforations and 20 eyes where there had been microbial keratitis which had responded to medical therapy leaving a scarred cornea. This latter group had both a better five year survival (90%) compared to all the others (51%), p less than 0.05, and achieved significantly better visual acuities, p less than 0.005.