Сквозная кератопластика у детей: результаты хирургического лечения

Abstract

Penetrating keratoplasty (PK) in children is a complex and ultifaceted problem that has been experiencing pediatric ophthalmology for several decades With all its radicality and with all its therapeutic potential, most surgeons prefer, nevertheless, to refuse to transplant the cornea in childhood, and transfer it to a later date, especially in infants (up to a year). In the absence of alternative interest in this operation did not fade, the practice of corneal transplantation in children continued and improved. The desirability of PK in corneal opacities (CO) in children is no longer discussed as such. On the agenda is another question: how to make this operation a truly effective way of treatment. This is not an easy task in itself, with many problems. Among them – the complexity of communication with a young patient, a special plasticity of the tissues of the child’s eye, heavy, as a rule, the combined nature of the pathology, predisposition to violent inflammatory reactions, etc. In many years of practice, for the most part, by trial and error, these problems are gradually finding their solution. An empirical experience always precedes the understanding of the problem and the search for its solution, no matter how unsuccessful it may seem at the very beginning. This work is devoted to generalization of such experience. Objective . To Evaluate the immediate and long-term results of penetrating keratoplasty in children. Material and methods. Retrospectively and prospectively analyzed the medical history and hospital records of children operated in the Department of pathology of eyes in children, Moscow Helmholtz Research Institute of Eye Diseases in the period from 1997 to 2017. The total sample consisted of 208 cases of the PK, was performed in 185 children on 208 eyes. By the nature of the disease, all observations were divided into congenital and acquired CO. Among the latter, turbidity of traumatic and non-traumatic nature was distinguished. Biological and functional results of PK were evaluated. The biological result of the operation was evaluated in terms of graft survival (Kaplan-Mayer model). The functional result was estimated approximately: by tracking the child’s toys from a certain distance and by the method of pr eferred gaze. Results . The first 6 months after the surgery, the transplants, with rare exceptions, remained transparent. By the end of the 1st year, 72% of transplants remained transparent, by the end of the 2nd year not less than 65%, by the end of the 3rd year-not less than 55%, by the end of the 5th year not less than 45% of transplants. In search of a more rigorous determination of the results, PK assessed the impact of particular clinical circumstances on the engraftment of transplants. It turned out that regardless of the etiology of the disease graft survival is significantly lower if keratoplasty is carried out in a vascularized couch, if simultaneously with corneal transplantation are other optical-reconstructive surgery: cataract extraction, vitrectomy, plastic iris, if the diameter of the transplant >8 mm, in the eyes with glaucoma in history. Transparency of transplants is significantly reduced in complicated postoperative course: recurrent rejection crises, increased IOP or the appearance of synechiae. In at least 80% of patients, corneal transplants have resulted in improved visual aquity (VA). In most of these cases, VA increased from light perception to 0.1-0.3. Satisfactory results, when VA after surgery reached 0.6-0.8, were in patients with keratoconus and congenital hereditary corneal dystrophy. Among those who have measured hundredth of VA dominated children with severe congenital malformations of the cornea and anterior segment of the eye. Conclusion . PK in children today is a very successful surgical intervention, the therapeutic potential of which can be realized with proper consideration of risk factors, impeccable technique and careful postoperative monitoring.