Changing trends in corneal graft surgery: a ten-year review

AIM: To review indications and corneal tissue use for penetrating and lamellar surgery between 2002 and 2011. METHODS: The surgical reports of corneal grafts performed during 2002-2011, using tissues supplied by the Eye Bank of Piedmont (Italy), were reviewed retrospectively. Patient demographic data, date of intervention, indication for surgery, and surgical technique used were recorded. Surgical techniques included penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK) and endothelial keratoplasty (EK). The χ2 test was used to compare the distribution of indications and types of surgical technique used, for corneal grafts done during 2002-2006 versus those done during 2007-2011. RESULTS: The number of corneal grafts increased by 30.7% from 2002-2006 to 2007-2011 (from 1567 to 2048). Comparing the two periods, both main indications and surgical techniques changed significantly. In 2007-2011, the proportion of interventions for aphakic/pseudophakic bullous keratopathy (from 16.8% to 21.3%), graft failure (from 16.4% to 19.1%) and Fuchs endothelial dystrophy (from 12.8% to 16.7%) all increased significantly (P<0.05), while those for keratoconus decreased significantly (from 35.6% to 27.3%; P<0.001). In 2007-2011, the proportion of PK decreased significantly (from 92.4% to 57.2%; P<0.001) while that of EK and DALK went from 0.4% to 30.2% (P<0.001) and from 7.2% to 12.6% (P<0.001) respectively. CONCLUSION: During 2002-2011 the number of interventions increased significantly for corneal endothelial diseases and graft failure. The growing demand for interventions for these diseases corresponded to the widespread adoption of EK techniques. The use of DALK also increased, but more moderately than EK procedures.     

Surgery for glaucoma in modern corneal graft procedures

Glaucoma is a common cause of vision loss after corneal transplantion and is considered a major risk factor for graft failure. Glaucoma may be present before corneal transplant surgery, or increased intraocular pressure may develop after keratoplasty in up to one-third of patients. Pre-existing glaucoma should be controlled before keratoplasty, either medically or surgically. For postkeratoplasty increase in intraocular pressure; identifying the risk factors allows appropiate follow-up and management. Patients undergoing anterior lamellar keratoplasty may take advantage of reduced rates of postkeratoplasty glaucoma. Glaucoma also complicates eyes with endothelial keratoplasties, mostly related to management of intraocular pressure spikes derived from anterior chamber air bubbles. Nevertheless, the severity is less, and the intraocular pressure is more easily controlled when compared with penetrating keratoplasty. Adequate management of glaucoma that develops before or after keratoplasty may save eyes from irreversible damage to the optic nerve and increase graft survival.     

Demographics of corneal transplantation in Canada in 2004

BACKGROUND: Penetrating keratoplasty (PKP) is the most frequently performed transplant surgery, and one of the most successful, yet no national study on the demographics of corneal transplantation in Canada has been published to date. The objectives of this study were to determine demographics of Canadian corneal transplant surgeons, donor tissue availability and waitlist length for each province, and limiting factors for the number of PKPs performed in Canada. METHODS: An anonymous voluntary survey of all Canadian corneal transplant surgeons was conducted between June and September 2004, with a concurrent voluntary survey of all eye banks in Canada. RESULTS: In 2004, there were 76 corneal transplant surgeons distributed as follows: British Columbia 17.1%, Alberta 11.8%, Saskatchewan 3.9%, Manitoba 7.9%, Ontario 36.8%, Quebec 17.1% and the Atlantic provinces 5.3%. The response rate of the Canadian corneal transplant surgeon survey was 69.7%. On average, each respondent performed 1 (SD 1) PKP/week, 40 (33) PKPs/year, and had a waitlist of 50 (63) patients. The mean wait time from date of referral to initial consultation was 10 (SD 7) weeks and from time of diagnosis to PKP was 51 (32) weeks. The most significant contributing factor to PKP waitlist selected by respondents in all provinces except Ontario was donor tissue shortage (64.7%); Ontario respondents (81.0%) believed that insufficient operating room time was the main factor. Ontario was the only province where all corneal transplant surgeons scheduled PKP electively and where surplus corneal tissue was regularly exported. INTERPRETATION: Recommendations include standardizing the criteria for acceptable donor tissue across all eye banks in Canada to increase efficiency of distribution, introducing and properly implementing mandatory referral and request legislation to increase donor rates, and increasing availability of operating room time for corneal transplant surgeons, especially in Ontario.     

手术治疗粥样角膜溃疡的临床疗效

目的：观察羊膜移植术和穿透性角膜移植术治疗粥样角膜溃疡的临床疗效。
　　方法：回顾性分析我院2009-02/2014-05临床确诊为“粥样角膜溃疡冶患者13例13眼,对其中药物治疗无效的患者进行羊膜移植术、穿透性角膜移植术治疗。术后随访4mo~2a,平均8mo,观察视力、溃疡愈合、复发等情况。
　　结果：患者3例经保守治疗角膜溃疡缓慢愈合,愈合时间为14~35(21±12.1) d,7例行羊膜移植术、2例行穿透性角膜移植术、1例角膜溃疡穿孔并光感丧失行眼球摘除术。羊膜移植术及穿透性角膜移植术后患者溃疡均得到治愈。所有患者随访期内未见复发。
　　结论：粥样角膜溃疡保守治疗难以奏效,大部分需手术干预。羊膜移植术和角膜移植术均可用于治疗粥样角膜溃疡,获得满意的临床疗效。但羊膜移植术相对简单、易行,适合基层医院推广。     

角膜小穿孔的手术治疗临床效果观察

目的观察总结角膜小穿孔的手术治疗效果。方法对12例13眼角膜小穿孔分别行穿透性角膜移植术、异体角膜修补术和羊膜移植术治疗。结果随访2~23月,术后末次随访矫正视力<0.1者2眼、0.1~0.4者5眼、≥0.5者6眼;12眼术后视力较术前提高,1眼下降。4眼发生暂时性高眼压。8眼行异体角膜修补术者,植片均浑浊;3眼行穿透性角膜移植术者,角膜植片保持透明;2眼行羊膜移植术者,角膜穿孔愈合,术区局部浑浊。结论累及瞳孔区的角膜小穿孔适合穿透性角膜移植术以获得较好视力;≤3 mm偏中心角膜小穿孔适合采用异体角膜修补和羊膜移植术。     

穿透性角膜移植术治疗基质层角膜营养不良

目的:探讨穿透性角膜移植术治疗基质层角膜营养不良的疗效。方法:对基质层角膜营养不良15例17眼施行穿透性角膜移植术,观察其临床特点及手术效果。随访6～36(平均18)mo。结果:术后视力比术前明显提高,最佳矫正视力>0.1者16眼(脱盲率94%),其中>0.3者9眼(脱残率52%)。2眼发生排斥反应,未发现原发角膜病变复发。结论:穿透性角膜移植术是治疗基质层角膜营养不良的有效方法。     

Effect of corneal graft diameter on therapeutic penetrating keratoplasty for fungal keratitis

AIM: To evaluate the effect of corneal graft diameter on therapeutic penetrating keratoplasty (PKP) for fungal keratitis. METHODS: A total of 116 patients (116 eyes) suffered from fungal keratitis underwent PKP at the Affiliated Hospital of Medical College Qingdao University from May 2006 to May 2010. They were divided into two groups according to the corneal graft diameter. 64 eyes’ corneal graft diameter was 8.00mm or larger and 52 eyes’ graft diameter was smaller than 8.00mm. The follow-up time was 2 years. The postoperative visual acuity and complications were documented and compared. RESULTS: Sixty-two (96.88%) eyes and fifty (96.15%) eyes preserved eyeballs respectively in two groups. There was no statistical difference in postoperative visual acuity (P=0.961), corneal graft clear rate (P=0.132) or the incidence of recurred fungal infection (P=0.770) between two groups. But there was a higher incidence of graft rejection (P=0.020) and secondary glaucoma (P=0.039) in group with corneal graft diameter 8.00mm or larger. CONCLUSION: PKP is an effective treatment approach for fungal keratitis. There is a higher incidence of complications in large-diameter PKP for fungal keratitis. Effective, preventive and therapeutic measures can improve the prognosis.     

复杂性角膜穿孔伤角膜移植手术对植片内皮细胞的观察研究

目的探讨复杂性角膜外伤后穿透性角膜移植手术角膜植片内皮细胞的变化。方法用角膜内皮显微镜对穿透性角膜移植联合手术12例（12眼）的术后移植片行内皮细胞摄像分析,并用超声角膜测厚仪测量术前供体角膜及术后移植片厚度。结果穿透角膜移植术后远期角膜内皮丧失率为34．98％,平均细胞面积明显增大,变异系数也明显增大,六角形细胞比例下降,但植片的厚度在正常范围内。其中11例移植片保持透明,表明多数未发生内皮细胞功能失代偿。结论穿透性角膜移植在严格掌握适应证的情况下是一种安全的方法,虽然移植片内皮细胞各种指标变化较大,但其厚度正常,透明成功率较高,所以穿透角膜移植联合手术仍不失为治疗复杂性角膜穿孔伤的良好办法。     

穿透性角移植治疗感染性角膜溃疡

目的:观察穿透性角膜移植术治疗感染性角膜溃疡的疗效和并发症。方法:对30例30眼严重的感染性角膜溃疡的患者进行穿透性角膜移植术,术后随访6～12mo,并进行回顾性总结。结果:本组病例中有25例角膜恢复透明(83%)。术后视力:视力<0.05者7眼,0.06～0.1者10眼,0.1～0.3者9眼,>0.3者2眼。5例发生继发性青光眼,7例出现免疫排斥反应,2例因感染不能控制而行眼球摘除。结论:穿透性角膜移植在严重感染性角膜的溃疡治疗中既可以控制疾病的发生和发展,又可以使患者的角膜恢复透明。但其并发症的防治是决定手术成败的关键。     

Corneal oedema after cataract surgery: predisposing factors and corneal graft outcome

Purpose: Pseudophakic bullous keratopathy (PBK) is one of the main indications for corneal transplantation. Graft survival and visual outcome in this group are often poorer than for other indications. The aim of this study was to find risk factors for developing corneal oedema after cataract surgery and factors that influence the subsequent survival of the graft and the visual outcome. Methods: We carried out an observational, retrospective cohort study using data from the Swedish Cornea Transplant Register and patient medical records. A total of 273 patients whose indication for corneal transplantation was corneal oedema after cataract surgery were included in the study. Multiple logistic regression analysis and, where appropriate, univariate analyses were applied. Results: A total of 43% of the patients developed persistent corneal oedema immediately after cataract surgery, the main risk factors for which were phacoemulsification and pre‐existing endothelial disease. Almost a third (32%) of the transplants for PBK failed within 2 years, for which rejection and other postoperative complications increased the risk. Half (50%) the patients had visual acuity ≤ 0.1 at 2 years after keratoplasty. Comorbidity, increasing duration of the bullous keratopathy and increasing age affected the visual outcome negatively. Conclusions: Phacoemulsification was a risk factor for immediate persistent corneal oedema after cataract surgery, although it did not increase the overall risk of developing PBK. However, transplants for immediate PBK had a better survival rate than those for later onset PBK. Shorter duration of PBK and intraocular lens exchange at the time of penetrating keratoplasty increased the likelihood of good visual acuity.     

角膜内皮移植治疗穿透性角膜移植术后植片失代偿的长期疗效观察

目的 观察角膜内皮移植手术（EK）治疗穿透性角膜移植术（PKP）后植片失代偿的长期临床效果。设计 回顾性病例系列。 研究对象 选取2008至2010年爱尔眼科医院收治的接受PKP术后植片内皮失代偿的患者6例（6眼）。 方法 对上述患者实施EK手术,对患者的临床资料进行回顾性分析。记录并分析患者术后视力、眼压、内皮细胞密度、排斥反应及并发症等。平均随访时间为（36.17±10.11）个月。主要指标  视力、眼压、内皮细胞密度、排斥反应及并发症。结果 术后所有患者植片均恢复透明,视力较前有不同程度提高,症状缓解。末次随访时,1例患者角膜失代偿,其余5例内皮细胞密度从986~1914个/mm2。随访期内,1例术后1天发生植片半脱位,经再次前房注气后贴附良好;1例术后5个月发生免疫排斥反应,经药物治疗植片保持透明;另1例患者未规律随诊,内皮移植术后26个月时发生排斥反应,导致失代偿。结论 对于反复发生免疫排斥反应导致植片混浊的高危患者,角膜内皮移植手术是可供选择的治疗方法。     

Topical Cyclosporin A in the treatment of acute graft rejection: a randomized controlled trial

Background:  Corneal graft rejection is the commonest cause of graft failure. Currently, intensive topical steroid is the treatment for graft rejection. We hypothesized that the use of topical Cyclosporin A (CsA) 0.05%, specifically Restasis (Allergan) in addition to intensive steroids would aid in the reversal and treatment of endothelial graft rejection.
Methods:  In a randomized double masked control study, we recruited 108 patients with acute endothelial graft rejection. They were randomized to two groups. The first group received intensive prednisolone acetate and placebo. The second group received intensive prednisolone acetate and Restasis.
Results:  There was no difference between the baseline characteristics for the two groups. Nine out of 54 in the placebo group and five out of 54 (16.7% vs. 9.2% P  = 0.23) in the treatment group were exited from the study because of worsening signs despite treatment. No significant difference was found between the two groups for time to reversal and resolution. Side-effects of the treatment include increased intraocular pressure and punctate epithelial erosions. These changes most likely relate to the use of intensive prednisolone acetate.
Conclusion:  The use of commercially available CsA as an adjunct to topical steroids does not appear to improve the outcome of graft rejection.     

表面麻醉下穿透性角膜移植术治疗角膜穿孔伤的研究

目的探讨表面麻醉下行穿透性角膜移植手术（PKP）治疗角膜穿孔伤的可行性。方法回顾性分析10例（10眼）在表面麻醉下行PKP治疗角膜穿孔伤的临床资料。结果所有患者均能耐受和配合手术,8例术后视力均得到不同程度的提高。术后植片透明7例,透明率为70．00％,其中1例甘油冷冻保存的角膜术后植片浑浊,1例因排斥反应导致植片浑浊,另1例因继发性青光眼后角膜失代偿导致植片浑浊。结论表面麻醉下行PKP是治疗角膜穿孔伤的一种安全有效的方法。     

角膜移植的研究进展

角膜移植是用透明、健康的供体角膜组织替换混浊病变的角膜组织,使患者复明或控制角膜病变,达到增进视力或治疗某些角膜疾病的眼科治疗方法.传统角膜移植分为穿透性角膜移植和板层角膜移植.近10a,深板层角膜移植和内皮细胞移植手术逐渐崛起.而目前,人工角膜移植手术的发展为不适合传统穿透性角膜移植手术的患者提供一种新的选择.本文综述了目前角膜移植领域手术技术的适应证、术后并发症等.     

斑状角膜营养不良治疗的研究进展

斑状角膜营养不良(macular corneal dystrophy,MCD)是一种常染色体隐性遗传病,是由角膜基质层营养不良导致的进行性视野缺损。CHST 6基因的突变被认为是其主要致病因素。一般来说,全厚度穿透性角膜移植术可作为提高患者视力的一种标准治疗手段。然而一些其它的外科干预措施如深板层角膜移植术(deep anterior lamellar keratoplasty,DALK)和准分子激光治疗性角膜切除术(phototherapeutic keratectomy,PTK)在治疗MCD中也显示了其有效性。一些新的治疗技术如基因靶向疗法和酶替代疗法,也正在被积极地研究。本文就其发病机制、遗传基础、临床表现、治疗及预后作一简要综述。     

穿透性角膜移植治疗重症真菌性角膜溃疡效果观察

目的探讨穿透性角膜移植治疗重症真菌性角膜溃疡的临床效果。方法对重症真菌性角膜溃疡10例(10眼)行穿透性角膜移植术,随访3~6月。结果术后10眼感染全部得到控制,8眼植片透明,1眼行二次穿透性角膜移植,术后角膜透明。术后视力均比术前提高。结论穿透性角膜移植治疗真菌性角膜溃疡可有效地控制感染,改善视功能,效果较好。     

干燥保存角膜供体行穿透性角膜移植治疗大面积严重感染性角膜溃疡

目的 观察用某油或无水氯化钙保存角膜材料的大面积穿透性角膜移植治疗严重感染性角膜溃疡的临床疗效。方法 对药物治疗无效的3例细菌性角膜溃疡,合并8.0～8.5mm直径的角膜溶解、穿孔;5例真菌性我膜溃疡,溃疡浸润范围均大于7.5mm,浸润深达全层,2例合并小穿孔,3例合并前房积脓。用甘油或无水氯化钙保存的角膜材料行大面积穿透性角膜移植。结果 7例感染控制,其中5例移植片保持半透明,2例新生血管长入,1例经2次角膜移植感染仍不能控制,最后做眼内容物摘除术。结论 在没有新鲜角膜材料来源时,用甘油或无水氯化钙保存角膜材料对严重感染性角膜溃疡行大面积治疗性穿透性角膜移植是一种有效的方法。     

Postoperative suture manipulation for control of corneal graft astigmatism

Purpose: To assess the effect on post-keratoplasty astigmatism of postoperative manipulation of a single running suture. Methods: All corneal transplant patients in whom a single 10/0 nylon running suture was placed between November 1990 and April 1996 were included in a prospective study of the effect of manipulation of the suture at the earliest possible time after surgery when the keratometry became possible by virtue of the epithelial surface integrity and where this revealed astigmatism of greater than 2 D. Results: One hundred and ninety eyes underwent suture manipulation and were followed up. Follow up on 30 eyes was discontinued. Repeat manipulation of the running suture was the most common reason for discontinuation of follow up. The remaining patients were followed for a mean (± SD) 415.5 ± 326.4 days. Mean astigmatism of 7.8 ± 3.1 D was reduced to 1.7 ± 2.0 D immediately after manipulation, but regressed to 3.0 ± 1.9 D (n= 76) by 1 year. The suture was removed in 32 patients. Twenty-five eyes had post-removal astigmatism measurements. In these 25 eyes, astigmatic error appeared not to revert to premanipulation levels. The only significant complication was one broken suture at manipulation. Conclusions: Early suture manipulation is effective in reducing suture in post-keratoplasty astigmatism, but some regression is seen.