Large Penetrating Keratoplasty Research Articles

Amniotic Membrane Transplantation-A Surgical Alternative in Peripheral Ulcerative Keratitis

Introduction: Peripheral ulcerative keratitis (PUK) is a group of inflammatory corneal ulcers with stromal thinning and peripheral localization. It begins with immune cellular infiltrates in the juxtalimbal cornea, followed by a crescent-shaped ulcer that appears parallel to the limbus. Medical management includes intense lubrication, antibiotics, along with topical and systemic steroids and immunosuppressants. Definitive surgical management is lamellar patch or penetrating corneal graft. Amniotic membrane has wide array of biological properties, including anti-inflammatory, anti-bacterial, anti-angiogenic, antifibrotic, healing properties hence can be used as an alternative to keratoplasty. Material and Methods: This mono institutional observational retrospective study was conducted on 15 eyes of 15 patients having PUK in a tertiary health care centre. Patients underwent single-layered amniotic membrane transplantation (AMT) in case of corneal thinning involving <1/2 corneal stroma, multi-layered or rolled AMT in cases of corneal thinning involving >1/2 corneal stroma or with moderate to large perforations along with systemic steroids and immunosuppression. Results: All 15 Patients (100%) initially had symptomatic relief,2 patients (13.33%) underwent repeat AMT (86%success rate), 2 failures were noted, out of which 1 patient (6.67%) underwent corneal patch graft while 1 patient (6.67%) underwent large penetrating keratoplasty which failed and landed in Phthisis. Conclusion: AMT is a safe and effective alternative for the surgical management of PUK in combination with local and systemic immunosuppressive therapy. A close collaboration between the ophthalmologist and the physician is mandatory to prevent corneal perforation and decrease patient morbidity and risk of mortality

Large Penetrating Keratoplasty in the Management of Keratoglobus: A Case Report

Background: Keratoglobus is a rare noninflammatory corneal disorder characterized by diffuse corneal thinning and globular protrusion of the cornea. Surgical management of keratoglobus is challenging and the standard method has not yet been defined. Aim: To present the role of large penetrating keratoplasty (PK) in the management of keratoglobus. Case Presentation: A 29-year-old male patient with bilateral keratoglobus presented with acute corneal hydrops in his right eye following extensive Descemet’s membrane rupture, with a visual acuity in this eye limited to hand movement. Peripheral cornea was extremely thin and blue sclera was present. Acute hydrops was managed conservatively at this stage and two months later large PK was performed in the right eye using 9.5 mm diameter graft over a 9 mm patient’s cornea trephination. Minor aqueous leakage was seen on the first postoperative day, managed with 2 more interrupted 10.0 nylon sutures. No further complications were noticed and postoperative course was uneventful. Fifteen months postoperatively the graft was clear and best corrected visual acuity was 20/60. Conclusions: Large penetrating keratoplasty has an important role in the management of keratoglobus, in cases where peripheral tuck-in lamellar keratoplasty or epikeratoplasty present serious intraoperative difficulties in host lamellar dissection and in stabilizing the graft due to extensive peripheral corneal and scleral thinning.

Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital.

PurposeTo report surgical therapies for corneal perforations in a tertiary referral hospital.MethodsThirty-one eyes of 31 patients (aged 62.4±18.3 years) with surgically treated corneal perforations from January 2002 to July 2013 were included in this study. Demographic data such as cause of corneal perforation, surgical procedures, and visual outcomes were retrospectively analyzed.ResultsThe causes of corneal perforation (n=31) were divided into infectious (n=8, 26%) and noninfectious (n=23, 74%) categories. Infectious causes included fungal ulcer, herpetic stromal necrotizing keratitis, and bacterial ulcer. The causes of noninfectious keratopathy included corneal melting after removal of a metal foreign body, severe dry eye, lagophthalmos, canaliculitis, the oral anticancer drug S-1, keratoconus, rheumatoid arthritis, neurotrophic ulcer, atopic keratoconjunctivitis, and unknown causes. Initial surgical procedures included central large corneal graft (n=17), small corneal graft (n=7), and amniotic membrane transplantation (n=7). In two cases the perforation could not be sealed during the first surgical treatment and required subsequent procedures. All infectious keratitis required central large penetrating keratoplasty to obtain anatomical cure. In contrast, several surgical options were used for the treatment of noninfectious keratitis. After surgical treatment, anatomical cure was obtained in all cases. Mean postoperative best corrected visual acuity was better at 6 months (logMAR 1.3) than preoperatively (logMAR 1.8).ConclusionSurgical therapies for corneal perforations in our hospital included central large lamellar/penetrating keratoplasty, small peripheral patch graft, and amniotic membrane transplantation. All treatments were effective. Corneal perforation due to the oral anticancer drug S-1 is newly reported.

Survival of Mushroom Keratoplasty Performed in Corneas With Postinfectious Vascularized Scars

To report the visual outcomes and graft survival rates of mushroom keratoplasty for the treatment of postinfectious corneal scars. Prospective, noncomparative, interventional case series. A microkeratome-assisted mushroom-shaped keratoplasty was performed in 31 eyes of 31 patients with a central vascularized full-thickness leukoma, resulting from infectious keratitis of various origin (herpes simplex virus, n = 16; bacteria, n = 10; Acanthamoeba, n = 5), with healthy endothelium. The donor graft consisted of a large anterior stromal lamella (9.0 mm in diameter and ± 250 μm in thickness) and a small posterior button (5 to 6 mm in diameter). Visual acuity, refraction, and endothelial cell density were evaluated before surgery, as well as at 12, 24, and 36 months after surgery, and the postoperative graft survival rate was evaluated. Three years after surgery, in 26 (83.8%) of 31 patients, best spectacle-corrected visual acuity was 20/40 or better with a refractive astigmatism of 4.5 diopters or less. The endothelial cell count at the last follow-up examination averaged 1584 ± 381 cells/mm(2), with an average cell loss of 40.7% from the preoperative value. The survival rate at 3 years was 90.3%, improving to 96.7% when excluding nonimmunologic causes for graft failure. Similarly to penetrating keratoplasty, microkeratome-assisted mushroom keratoplasty restores vision in eyes with postinfectious, full-thickness, central corneal scars. For these vascularized corneas at high risk for immunologic rejection, mushroom keratoplasty combines the visual and refractive advantages of large penetrating keratoplasty grafts with the high survival rate of small penetrating keratoplasty grafts.

Mushroom keratoplasty in pediatric patients

Objective To report the outcome of mushroom keratoplasty for the treatment of full thickness corneal disease in pediatric patients with healthy endothelium. Methods A retrospective analysis of pediatric patients who underwent mushroom keratoplasty. The medical records of pediatric patients suffering from full thickness corneal stromal disease with normal endothelium who underwent mushroom keratoplasty at our Institution were included. A two-piece donor graft consisting of a large anterior stromal lamella (9.0 mm in diameter and ±250 μm in thickness) and a small posterior lamella (5–6.5 mm in diameter) including deep stroma and endothelium, prepared with the aid of a microkeratome had been transplanted in all cases. Ophthalmic examination including slit lamp examination, best corrected visual acuity, and corneal topography was performed preoperatively and at each postoperative visit on all patients. The endothelial cells were assessed by specular microscopy in these patients. Results Six eyes of six patients (five males and one female) were included. The mean age was 9.3 years (range 5–15 years). Average follow-up was 17.8 months (range 9–48 months). There were no early or late complications recorded. All corneas were clear at the last follow up visit. Preoperative best corrected visual acuity (BCVA) was worse than 20/70 in all six eyes. Postoperatively, four eyes achieved BCVA of 20/40 or better. Endothelial cell loss ( n eyes = 3 averaged 24% (range 19–31%). The mean endothelial cell loss was 24% (range 19–31%) among these patients. Conclusions Microkeratome assisted mushroom keratoplasty is a viable surgical option for pediatric eyes with full thickness corneal stromal disease and healthy endothelium. Mushroom keratoplasty combines the refractive advantage of a large penetrating keratoplasty with the survival advantage of a small penetrating keratoplasty. Furthermore, mushroom keratoplasty exhibits the mechanical advantage of a shaped keratoplasty.

Corneal Chromoblastomycosis

We sought to illustrate the difficulty in managing uncommon, pigmented mold-related corneal ulceration and to highlight the role of itraconazole in treating these patients. We describe the management and clinical course of a patient with a recurring corneal infection caused by Fonsecaea pedrosoi and discuss this experience in the light of existing literature on management of cutaneous chromoblastomycosis. A corneal ulcer caused by this organism healed initially on treatment with topical and systemic antifungal medication, but infection recurred in the deep stroma 4 months after cessation of therapy. After failure to respond to a further period of medical therapy, a small therapeutic penetrating keratoplasty was performed. Culture of a fibrinous membrane from the anterior iris surface demonstrated intraocular fungal infection, and postoperatively, an episode of marked fibrinous uveitis developed, suggesting the presence of viable intraocular fungal elements. A large penetrating keratoplasty was therefore performed with excision of involved iris in combination with extracapsular cataract extraction. F. pedrosoi was again cultured from the fibrinous membrane adherent to the iris and from the anterior lens capsule. Postoperatively the patient received a 5-month course of systemic itraconazole, and no further recurrences have been encountered after a further 2 months. F. pedrosoi is the organism most commonly isolated from the chronic cutaneous mycosis, chromoblastomycosis, and is relatively resistant to medical therapy. As has been reported for cutaneous disease, surgery in combination with systemic itraconazole may provide the best chance of cure in corneal chromoblastomycosis.

Results of Large Penetrating Keratoplasty in Microbial Keratitis

Extensive corneal disease secondary to microbial keratitis can result in frank or impending corneal perforation requiring a large penetrating keratoplasty. In an 8-year period, 26 penetrating keratoplasties with recipient beds of > or = 9.5 mm were performed on 22 eyes: 11 for bacterial keratitis, 10 for fungal keratitis, and one for a mixed bacterial and fungal keratitis. The graft failed in 18 of 19 eyes (94.7%), with a median time to failure of 12.9 weeks in bacterial keratitis and 4.0 weeks in fungal keratitis. After large keratoplasty, 17 of 20 eyes (85.0%) maintained the structural integrity of the globe. The remainder became phthisical or required enucleation. With preservation of the structural integrity of the globe, a subsequent smaller optical penetrating keratoplasty is an option in some of these eyes.