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Nkanga ED, Umana UE, Ibanga AA, Nkanga ED, Ezeh EI, Ani EU, Nkanga DG, Etim BA, Akpan SI. Pediatric Corneal Transplantation in Uyo, Nigeria: Early Experiences. Niger J Clin Pract 2023; 26:1772-1776. [PMID: 38044787 DOI: 10.4103/njcp.njcp_459_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/11/2023] [Indexed: 12/05/2023]
Abstract
ABSTRACT The burden of avoidable blindness from corneal disease is significantly higher where access to specialist eye care, the cost of treatment and the treatment infrastructure including eye banking, are beyond the reach of the impoverished masses. Corneal transplantation in children is challenging: it is more technically complex; patients often require multiple examinations under general anaesthesia to optimize treatment outcomes. There is also the increased risk of several complications including graft dehiscence, infection, rejection, and inappropriate patient or caregiver care. However, when successful, it restores vision. We present a report of our initial experience with penetrating keratoplasty in 2 children with blinding corneal disease in Uyo, Nigeria. Corneal transplantation history was retrieved and data (including data on age, sex, aetiology of corneal disease, indications for corneal transplantation, pre-operative and post-operative visual acuity and intraocular pressure measurements) was extracted for this report. Both patients had standard penetrating keratoplasty performed by one surgeon, under general anaesthesia. Case one was a 10-year-old male presenting with profound visual impairment from congenital hereditary endothelial dystrophy. His best corrected post-operative visual acuity was 6/24. Case two was a 3-year-old male with vision loss due to a corneal leucoma following treated herpes simplex keratitis. Post-operatively, his best corrected visual acuity improved to 6/12. Corneal graft tissue remained clear at more than 3 years of follow-up. Although amblyopia was a notable co-morbidity, corneal transplantation significantly improved their vision. Corneal banking services are advocated for in resource-limited settings where the magnitude of corneal blindness is greatest.
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Affiliation(s)
- E D Nkanga
- Paediatric Ophthalmology and Strabismus Unit, Department of Ophthalmology, University of Calabar, Calabar, Cross River State, Nigeria
| | - Ui E Umana
- Department of Ophthalmology, Marion Eye Centre, Marion, Illinois, USA
| | - A A Ibanga
- Department of Ophthalmology, University of Calabar, Calabar, Cross River State, Nigeria
| | - E D Nkanga
- Department of Pediatrics, All Saints University of Medicine, Common Wealth of Dominica, Rivers State, Nigeria
| | - E I Ezeh
- Department of Ophthalmology, University of Calabar, Calabar, Cross River State, Nigeria
| | - E U Ani
- Department of Ophthalmology, The Ophthalmic Specialists, Port Harcourt, Rivers State, Nigeria
| | - D G Nkanga
- Department of Ophthalmology, University of Calabar, Calabar, Cross River State, Nigeria
| | - B A Etim
- Department of Ophthalmology, University of Calabar, Calabar, Cross River State, Nigeria
| | - S I Akpan
- Department of Ophthalmology, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
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Gour A, Garg A, Tibrewal S, Pegu J, Gupta S, Mathur U, Sangwan V. Corneal transplantation in children - when and how? EXPERT REVIEW OF OPHTHALMOLOGY 2023. [DOI: 10.1080/17469899.2023.2177153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Abha Gour
- Department of Cornea and Anterior Segment Services, Dr Shroffs Charity Eye Hospital, New Delhi
| | - Aastha Garg
- Department of Cornea and Anterior Segment Services, Dr Shroffs Charity Eye Hospital, New Delhi
| | - Shailja Tibrewal
- Department of Pediatric Ophthalmology, Strabismus and Neurophthamology, Dr Shroffs Charity Eye Hospital, New Delhi
| | - Julie Pegu
- Department of Glaucoma and Anterior Segment Services, Dr Shroffs Charity Eye Hospital, Dr Shroffs Charity Eye Hospital, New Delhi
| | - Sonal Gupta
- Department of Cornea and Anterior Segment Services, Dr Shroffs Charity Eye Hospital, New Delhi
| | - Umang Mathur
- Department of Cornea and Anterior Segment Services, Dr Shroffs Charity Eye Hospital, New Delhi
| | - Virender Sangwan
- Department of Cornea and Anterior Segment Services, Dr Shroffs Charity Eye Hospital, New Delhi
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Abstract
PURPOSE Congenital hereditary endothelial dystrophy (CHED) is a rare, autosomal recessive, monogenic corneal condition with variable expressivity. Often presents in bilateral symmetrical progressive corneal cloudiness that starts in the early infancy. It is characterized by increased corneal thickness, profound corneal edema, and thickening of the Descemet membrane due to endothelial dysfunction. The published literature lacks uniform guidelines for grading corneal cloudiness and management algorithm for CHED cases. This article focuses on applying newer investigational modalities to fine-tune surgical outcomes and more recent CHED management strategies. METHODS This comprehensive literature review was performed based on a search on the PubMed database of relevant CHED articles focusing on those published in the last 7 years. A total of around 70 articles were reviewed, and 17 of them were included in this review. These include systemic reviews, randomized controlled clinical trials, cohort studies, case-controlled studies, and case series. RESULTS Corneal cloudiness grading in CHED using subjective and objective methods using Anterior Segment Optical Coherence Tomography (AS-OCT) and densitometry using Scheimpflug imaging can help select appropriate management plan for CHED cases. DSAEK outscores penetrating keratoplasty with much fewer complications and expedites visual recovery, which helps mitigate amblyopia. CONCLUSION Managing cases of CHED has been a challenge due to the dilemma in timing and appropriate surgical method selection and lack of definitive medical or other conservative approaches. Currently, DSAEK has shown favorable results in cases of CHED. However, appropriate staging of CHED and selecting the appropriate management approach appears to play a critical role in managing such cases. Besides these, novel treatment modalities such as nonsteroidal anti-inflammatory agents (NSAIDS) that target restoring water-flux activity in subtype of CHED and gene editing using CRISPR-Cas9 are promising paradigm treatment modalities.
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Affiliation(s)
- Neet Mehta
- Academy of Eye Care Education, L V Prasad Eye Institute, Hyderabad, India
| | - Muralidhar Ramappa
- Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, India.,The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.,Ramanamma Children's Eye Care Center, L V Prasad Eye InstituteJasti V , Hyderabad, India
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Gurnani B, Kaur K, Lalgudi VG, Tripathy K. Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review. Clin Ophthalmol 2023; 17:421-440. [PMID: 36755886 PMCID: PMC9899935 DOI: 10.2147/opth.s398418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Descemet membrane endothelial keratoplasty (DMEK) is a corneal endothelial transplantation procedure with selective removal of a patient's defective Descemet membrane and endothelium. It is replaced with a healthy donor Descemet membrane and endothelium without a stromal component. Corneal graft rejection can be at the level of epithelium, stroma as well endothelium. DMEK graft rejection is relatively less common than rejection with DSAEK or penetrating keratoplasty, and a good outcome may be achieved with prompt management. The clinical picture of DMEK rejection is usually similar to endothelial rejection in Descemet Stripping Endothelial Keratoplasty (DSEK/DSAEK), which generally manifests as pain, redness, reduction in visual acuity, stromal edema, endothelial rejection line, keratic precipitates at the back of the cornea and corneal neovascularization. However, more subtle forms of rejection or immune reactions are more common in DMEK compared to DSAEK eyes. Early clinical diagnosis, prompt intervention, and meticulous management safeguard visual acuity and graft survival in these cases. Intensive topical steroids form the mainstay in the management of DMEK rejection. Sometimes, oral or intravenous steroids or other systemic immunomodulators may be required. DMEK graft failure can be primary or secondary, and failure usually requires a second procedure in the form of repeat DMEK or DSEK or penetrating keratoplasty (PKP). A detailed literature search was performed using search engines such as Google Scholar, PubMed, and Google books, and a comprehensive review on DMEK rejection was found to be lacking. This review is a comprehensive update on the risk factors, pathophysiology, primary and secondary graft failure, recent advances in diagnosis, prevention of rejection, and updates in the management of DMEK rejection. The review also discusses the differential diagnosis of DMEK failure and rejection, prognosis, and future perspectives considering DMEK failure and rejection.
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Affiliation(s)
- Bharat Gurnani
- Department of Cornea and Refractive Surgery, Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust, Janaki-kund, Madhya Pradesh, India,Correspondence: Bharat Gurnani, Consultant, Cataract, Cornea, External Diseases, Trauma, Ocular Surface, Uvea and Refractive Surgery, Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust, Janaki-kund, Madhya Pradesh, 485334, India, Tel +919080523059, Email
| | - Kirandeep Kaur
- Department of Pediatric Ophthalmology, Sadguru Netra Chikitsalaya, Shri Sadguru Seva Sangh Trust, Janaki-kund, Madhya Pradesh, India
| | | | - Koushik Tripathy
- Department of Vitreoretinal and Cataract, ASG Eye Hospital, Kolkata, West Bengal, India
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Pellegrini M, Salgari N, D'Angelo S, Caruso L, Franco E, Bovone C, Spena R, Zauli G, Busin M, Yu AC. 10-year experience with lamellar keratoplasty for the surgical Management of Paediatric Corneal Diseases. Acta Ophthalmol 2022; 100:e1306-e1312. [PMID: 35678335 DOI: 10.1111/aos.15199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the outcomes of various lamellar keratoplasty techniques performed at our Institution in children aged 14 years or younger over the last decade. METHODS This single-centre study reviewed 72 eyes that underwent lamellar keratoplasty for various indications. Deep anterior lamellar keratoplasty (DALK) was performed in 19 eyes, mushroom penetrating keratoplasty (PK) in 27 eyes and Descemet stripping automated endothelial keratoplasty (DSAEK) in 25 eyes. The main outcome measures included best spectacle-corrected visual acuity (BSCVA), complications and rate of graft failure which was defined as any graft requiring repeat transplantation. RESULTS Best spectacle-corrected visual acuity (BSCVA) significantly improved after DALK, mushroom PK and DSAEK (all p < 0.05), with 50%, 60% and 56% of eyes reaching ≥20/40, respectively. Stromal rejection was observed in 1 eye (5.3%) after DALK, whilst endothelial rejection occurred in 1 eye after mushroom PK (3.7%) and 1 eye after DSAEK (4.0%). Overall survival was 100% after DALK (mean follow-up: 23.0 months), 92.8% after mushroom PK (mean follow-up: 42.3 months) and 96.0% after DSAEK (mean follow-up: 33.6 months). CONCLUSION Deep anterior lamellar keratoplasty (DALK), mushroom PK and DSAEK offer good visual outcomes for children with corneal pathology, with low rates of immunological rejection and graft failure.
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Affiliation(s)
- Marco Pellegrini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Niccolò Salgari
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Sergio D'Angelo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Lorenzo Caruso
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Elena Franco
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Cristina Bovone
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Rossella Spena
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Giorgio Zauli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Research Department, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
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