Epithelial cyst in the anterior chamber after penetrating keratoplasty: a rare complication.

We report the case of a 25-year-old man who had a penetrating keratoplasty for keratoconus. A year and a half after surgery a cyst was noted in the anterior chamber, which was observed to enlarge over six months. Because of anxiety about endothelial touch, it was removed surgically. Histologically the cyst was composed of stratified, non-keratinized squamous epithelium attached to loose fibrovascular tissue including islands of melanin-containing epithelial cells. This was interpreted as an epithelial implantation cyst of the anterior chamber of corneal origin attached to iris tissue.     

Corneal edema and penetrating keratoplasty after anterior chamber phakic intraocular lens implantation

Phakic intraocular lens (IOL) implantation is an increasingly popular option in surgical correction of refractive error. To date, reports of long-term morbidity are infrequent in the literature. We encountered 3 patients who experienced corneal decompensation and cataract progression following angle-fixated anterior chamber phakic IOL placement.     

无前房复杂性穿透性角膜移植术的方法探讨

目的 为提高手术成功率,减少并发症,对无前房复杂性穿透性角膜移植手术的方法和技巧进行改革。方法 １４例（１４眼）无前房的;穿透性角膜移植手术,术中采用了制作球结膜瓣和巩膜瓣以利引流的方法,并在分离虹膜前后粘连形成的前房及白内障摘出和同期人工晶状体植入的方法上进行了改良。结果 随访６～１２个月,其中１２眼植片透明,２眼半透明,取得了满意效果。结论 探讨了改进手术方法的解剖生理依据,证明了此方法在临床     

Immunologic graft reactions after allogenic penetrating keratoplasty

PURPOSE: To evaluate frequency and risk factors of immunologic graft reactions after allogenic penetrating keratoplasty. DESIGN: Interventional comparative nonrandomized clinical trial. METHODS: The setting took place in a university eye hospital. The retrospective study included 338 patients (338 eyes). The patients underwent penetrating keratoplasty performed by a single surgeon in the study period from 1989 to 1997. Follow-up period had to be longer than 12 months (mean +/- SD, 31.4 +/- 18.8 months). Frequency of immunologic graft reactions characterized by relatively few small monomorph whitish cells in the anterior chamber, almost no flare, and retrocorneal cellular precipitates. RESULTS: Immunologic graft reactions were detected in 46 patients (46/338 = 13.6%). Statistically significant risk factors for the development of graft reactions were loosening of sutures (P =.046), and preoperative and postoperative corneal vascularization (P =.04). Frequency of an immunologic graft reaction was statistically independent (P >.05) of the graft diameters used in the present study, age, and gender of the patients, HLA-typing, donor age, and preservation data of the donor material. Seventy-four percent (34/46) of all graft reactions were detected within the first 2.5 years after surgery. Thirteen percent (6/46) of all graft reactions were observed more than 4 years after keratoplasty. With intensive corticosteroid treatment, graft transparency could be regained in 44 (95.6%) of the 46 patients with an immunologic graft reaction. CONCLUSIONS: Most important risk factors for immunologic graft reactions occurring in approximately 14% of patients after allogenic penetrating keratoplasty are suture loosening and preoperative and postoperative corneal vascularization. Graft diameters as used in the present study, HLA-typing, age of the donor, and preservation data of the donor material may not play a major role. More than 10% of graft reaction episodes can occur more than 4 years postgrafting. With intensive corticosteroid treatment, graft transparency can be regained in the majority of patients after an immunologic graft reaction when detected early.     

Clinical aspects and treatment of immune reactions following penetrating normal-risk keratoplasty

PURPOSE: Endothelial graft rejection is one of the most common causes of graft failure following penetrating keratoplasty (PK). The aim of this study was to evaluate the incidence, time course and outcome of treatment of graft rejection after normal-risk PK and to identify possible risk factors for the recurrence of immune reactions and irreversible graft failure. PATIENTS AND METHODS: The study included 500 eyes from the prospective Erlanger Normal-risk Keratoplasty Study with a mean follow-up of 42 +/- 18 (median 40) months. Indications for PK were keratoconus in 48 %, Fuchs' dystrophy in 30 %, secondary bullous keratopathy in 11 %, non-vascularized corneal scars in 7 % and stromal dystrophies in 4 %. Standardized complete ophthalmological examinations were performed on a regular basis before, during the acute graft rejection and then regularly in a defined examination raster in an cornea out-patient service. RESULTS: During follow-up 29 eyes (5.6 %) developed an episode of endothelial graft rejection (23 eyes with acute diffuse and 6 eyes with chronic focal rejection type). Episodes of endothelial graft rejection clustered between 11 and 25 months postoperatively (15 from 29, 51.7 %). Most grafts (25 of 29) regained clarity after topical and systemic steroid treatment. Only 4 patients showed an irreversible graft failure requiring a repeat PK, all of whom had secondary bullous keratopathy as the primary indication for PK. Risk factors for irreversible graft failure were pre-existing anterior synechiae in 3 patients and secondary open angle glaucoma in pseudoexfoliation syndrome in one patient. Recurrence of graft rejection was seen in 5 patients (all with keratoconus) after a time interval of 8 to 12 months. Under very low topical steroid treatment no further recurrence was observed in all 5 patients up to 2 years. CONCLUSION: Patients should be followed-up on a regular base for longer postoperative periods, since most episodes of graft rejection were observed between 1 and 2 years after PK. Development of irreversible graft failure was strongly associated with pre-existing anterior synechiae and pre-existing glaucoma. Low-dose topical steroid treatment after immunological rejection seems to prevent the recurrence of further graft rejection.     

穿透性角膜移植排斥反应的免疫学机制

尽管角膜具有众多特殊的免疫赦免机制,但CD4+T细胞为主介导的角膜移植排斥反应仍是术后最常见的并发症.本文从高危角膜移植对免疫赦免状态的影响、角膜免疫机制的应答以及排斥反应的预防及治疗几个方面阐述角膜移植排斥反应的最新进展.     

穿透性角膜移植术后内皮型免疫排斥反应的临床研究

目的探讨穿透性角膜移植术(PKP)后内皮型免疫排斥反应发生的动态变化,及对角膜植片透明性的影响。方法对1994年1月至1998年12月在我院行PKP术并有完整记录的患者648例(648只眼),男444例(444只眼)、女204例(204只眼)进行随访,统计术后05、1、3、6、9、12、18、24、36、48个月等10个不同时间内皮型免疫排斥的发生率,以及植片混浊的发生率,比较两者动态变化的相关性,制成动态变化曲线,并对术前的病因与术后内皮型免疫排斥反应发生之间的关系进行分析。结果植片混浊与内皮型免疫排斥反应密切相关(线性相关回归分析,P<001);术后3年,内皮型免疫排斥反应的发生率仍有一定比例。术前不同病因及炎性背景的眼病,因内皮型免疫排斥反应发生率不同,而影响植片透明性。结论PKP术后,植片的透明性主要受内皮型免疫排斥反应的影响,二者密切相关;各种角膜疾病因炎性反应不同,其内皮型免疫排斥反应的发生率也不同,重视术后患者的长期随访,对维持术后角膜植片的透明性,保证手术成功率有重要意义。(中华眼科杂志,2005,41145149)     

Corneal radius of curvature after anterior lamellar versus penetrating keratoplasty

Background

Keratoplasty may induce major spherical refractive error related to abnormal corneal radius of curvature (CRC).

Methods

Two hundred and thirty-eight consecutive eyes of 238 patients with clear graft and at least one postoperative Orbscan examination performed after suture removal (average follow-up time, 86 months) were retrospectively analyzed. Anterior lamellar keratoplasties (ALK group, n?=?119) and penetrating keratoplasties (PK group, n?=?119) were matched for preoperative diagnosis and lens status.

Results

The average postoperative, suture-out, Orbscan 3-mm CRC was 7.17 mm with a wide 95 % confidence interval [6.26 mm; 8.37 mm]. It was 7.05 mm in the ALK group and 7.31 mm in the PK group (p?<?0.01). In the ALK group, this figure was 7.00 mm for oversized grafts and 7.67 mm for non-oversized grafts (p?<?0.001). CRC values were significantly lower for eyes with keratoconus (7.00 mm) or stromal scar after infectious keratitis (7.06 mm) compared with stromal scar after trauma (7.74 mm) or stromal dystrophies (8.17 mm). Values were significantly lower for big-bubble ALKs (6.92 mm) and manual dissection-ALKs (7.14 mm) compared with PKs (7.31 mm) and microkeratome-assisted ALKs (7.45 mm). The average Orbscan 3-mm SimK cylinder, irregularity, and refractive power symmetry index were, respectively, 4.7 D/4.8 D/1.9 D for ALKs and 5.2 D/4.8 D/1.8 D for PKs (p?=?0.99).

Conclusions

The CRC is lower after ALK compared with PK, and features important variability. In eyes with ALK, non-oversized grafts result in postoperative CRC close to normal values and corneal diseases associated with stromal thinning and DALK result in lower postoperative CRC.     

Double Descemet's membranes after penetrating keratoplasty with anterior segment optical coherence tomography

An 83-year-old man underwent penetrating keratoplasty for pseudophakic bullous keratopathy in the left eye. Postoperatively, a thin transparent membrane in the anterior chamber was noted. The differential diagnosis included vitreous prolapse, retained capsule, fibrinous anterior chamber membrane, and retained Descemet's membrane in the anterior chamber, but the diagnosis was uncertain due to corneal edema and Descemet's membrane folds. Anterior segment optical coherence tomography was used to determine the diagnosis of retained host Descemet's membrane. This case report demonstrates that anterior segment optical coherence tomography is a useful and noninvasive instrument for diagnosing and following complications from penetrating keratoplasty.     

Comparison of refractive changes after deep anterior lamellar keratoplasty and penetrating keratoplasty for keratoconus

Purpose  

To compare refractive changes occurring after deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PKP) in patients with keratoconus.     

Triple anterior chamber after full-thickness lamellar keratoplasty for lattice corneal dystrophy.

PURPOSE: To report a patient with lattice corneal dystrophy type I (LCDI) who developed a triple anterior chamber after full-thickness lamellar keratoplasty (LKP). METHODS: A 46-year-old woman underwent a full-thickness LKP in her right eye for visual disturbances caused by LCDI. Her visual acuity was 20/200 OD before surgery. A complete ophthalmic examination, including slit lamp biomicroscopy and optical coherence tomography (OCT), was performed before and after surgery. Molecular genetic analysis was performed on DNA extracted from the peripheral leukocytes. RESULTS: The surgery was performed uneventfully; however, extra spaces posterior to the graft, along with the severe graft edema, were observed to form a triple anterior chamber a few days after surgery. The extra spaces resolved in 3 weeks with no surgical treatment, and her visual acuity improved to 20/20 OD without correction 3 months after surgery. The triple anterior chamber was clearly demonstrated by OCT, but not by slit lamp biomicroscopy. A heterozygous single base-pair transition (CGC to TGC, arginin to cysteine) was detected in codon 124 of the TGFBIgene in the patient. CONCLUSION: The separation of the graft and the host's deep corneal tissue and a Descemet's membrane detachment in the host's cornea caused the triple anterior chamber. The Descemet's membrane detachment demonstrated the weak adhesion of the stroma and the Descemet's membrane, probably resulting from a dysfunction of the TGFBI protein caused by the mutation of the TGFBIgene. OCT is useful for the objective documentation of the posterior corneal region even with severe corneal edema.     

Chronic endophthalmitis mimicking an endothelial immune reaction after penetrating keratoplasty

We describe a patient with chronic inflammation after combined penetrating keratoplasty and cataract surgery. This condition has been considered an unusual endothelial immune reaction. Cytopathological examination of the aqueous humor showed abundant neutrophil granulocytes, a few macrophages, and sparse lymphocytes. The predominance of neutrophil granulocytes but no macrophages or lymphocytes, as found in cases of an endothelial immune reaction, was interpreted as evidence of chronic endophthalmitis. Cytopathological evaluation of aqueous humor can be a helpful tool for differentiating between an endothelial immune reaction and chronic endophthalmitis after combined PKP and cataract surgery.     

Long-term graft survival in patients with Down syndrome after penetrating keratoplasty

PURPOSE: To determine graft survival and long-term visual outcome after penetrating keratoplasty (PK) for keratoconus in patients with Down syndrome. METHODS: The records of all patients with Down syndrome who received PK by the same provider were reviewed. A retrospective analysis was performed to determine long-term graft survival, incidence of graft failure, and complication rate. RESULTS: Twenty-one PKs were performed on 18 eyes of 13 patients with Down syndrome with keratoconus. Three repeat PKs were performed for secondary graft failure. All 18 eyes had clear grafts at the most recent examination. Follow-up ranged from 4 to 88 months, with a mean of 34.9 months. The average age of patients was 42 years, with a range of 20 to 63 years. Preoperative visual acuity ranged from 20/160 to count fingers. Postoperatively, visual acuity was objectively measurable in 12 eyes of 8 patients and ranged from 20/30 to 20/200, with a mean of 20/60. Broken sutures and difficulties with unsedated suture removal complicated postoperative care in some patients. CONCLUSION: Clear grafts and improvements in visual acuity can be obtained after PK in patients with Down syndrome, but consideration must be given to careful postoperative care by health care providers and home support personnel.