Wound dehiscence after penetrating keratoplasty

PURPOSE: To assess the patient characteristics, risk factors, and outcomes of penetrating keratoplasty wound dehiscence. METHODS: Retrospective chart review of 30 eyes of 29 patients with corneal grafts who underwent repair of penetrating keratoplasty wound dehiscence from January 1, 1998 to December 31, 2003, followed on the Cornea Service at Wills Eye Hospital. RESULTS: The mean time from penetrating keratoplasty to wound dehiscence was 7.5 years (range 1 week to 31 years). The mean age at time of wound dehiscence was 66 years (range 28-98 years). One eye developed wound dehiscence following suture removal, whereas the remaining 29 eyes sustained trauma-induced dehiscences. Falls were the most common mechanism of trauma, especially in the elderly population. There was a wide range of visual outcomes in the 21 patients followed for 1 year, with 4 patients maintaining best corrected visual acuity between 20/20 and 20/40 and 5 patients with light perception vision at 1 year. There were no cases of endophthalmitis. CONCLUSIONS: Patients with corneal transplants have a life-long risk for wound dehiscence. This complication may be reduced by the regular use of eye protection in all corneal transplantation patients.     

Traumatic wound dehiscence after penetrating keratoplasty: clinical features and outcome in 21 cases.

PURPOSE: To describe the characteristics, causes, treatment, and outcome, particularly the fate of the intraocular implant and visual acuity, of traumatic wound dehiscence occurring in patients who had penetrating keratoplasty (PK). METHODS: Between 1989 and 1997, 21 corneal transplant patients sustained traumatic wound dehiscence and were treated at our hospital. Graft dehiscence was managed with primary wound closure in all patients, except in some who required some combination of anterior vitrectomy, intraocular lens removal and reimplantation, and corneal regrafting. RESULTS: The incidence of traumatic wound dehiscence among patients on whom we performed PK over a period of 9 years was 2.53%. This complication occurred, on average, 3.4 years (2 months to 13 years) after PK. Most patients (76%) were men, and the average age at dehiscence was 59 years (range, 15-82 years). All corneal ruptures occurred at the graft-host junction, which had neither particular site preference nor quadrant specificity. Of the 16 eyes that were pseudophakic, nine (56.3%) had either loss of implants or dislocation of intraocular lens so severe that lens removal was imperative. In the end, only five (23.8%) of the 21 grafts retained clarity. Of the remaining 16 eyes, seven were regrafted, of which five (71.4%) grafts remained clear. Of the nine grafts that became opaque, six eyes (28.6%) atrophied. At the last follow-up, only six eyes (28.6%) had visual acuity of 20/200 or better, and six eyes had no perception of light. Final visual acuity was found to correlate inversely with the severity and extent of wound separation. CONCLUSION: Traumatic wound dehiscence is not rare after PK. The elderly corneal transplant patient may be more prone to such an injury. Corneal rupture at the graft-host junction in all of our cases means the persistence of wound weakness after PK. Although graft survival and visual outcome are generally poor after the injury, the restoration of a satisfactory visual result is possible after regrafting, insofar as the involved eye is free of intractable glaucoma or posterior segment damage.     

穿透性角膜移植术后角膜植片哆开调查分析

目的分析穿透性角膜移植术后植片哆开的发生原因、时间、伤情与预后的关系等。方法收集山东省眼科研究所1993年～2004年间所行穿透性角膜移植(penetratingkeratoplasty,PKP)术3150例中发生角膜植片哆开的27例患者。详细记录患者角膜植片哆开的原因、时间、受伤程度、治疗、伤情与预后的关系等情况。结果(1)发生原因:碰伤11例,拳击伤9例,异物击伤5例,手指戳伤2例。(2)发生时间:70.4%的患者发生在术后两年内,其余散在分布,最短时间15天,最长时间12年。(3)受伤程度:角膜裂伤均沿角膜植片植床缝合处断开。5例植片哆开范围在1～3个钟点,16例在4～6个钟点之间,5例在7～9个钟点之间,1例植片完全脱落。植片哆开范围<6个钟点的患者共10例,4例发生了晶状体、虹膜及玻璃体脱出,植片哆开范围≥6个钟点的患者16例,均发生了晶状体、虹膜及玻璃体脱出。(4)治疗:10例单纯行角膜植片重缝术,11例行角膜植片重缝 前玻切术,5例联合视网膜复位术,1例眼内容剜除术。(5)伤情与预后:2例植片哆开范围小且未发生眼内容脱出的患者视力较伤前提高,其余视力均有不同程度下降。随着角膜植片哆开范围的增加,患者视力下降程度加重。结论PKP术后角膜植片哆开主要由外伤造成,术后两年内为高发期,眼部受伤的严重程度与预后密切相关。     

穿透性角膜移植术后创口裂开的临床观察

目的探讨穿透性角膜移植术后创口裂开的特点、治疗方法及对视功能的影响.方法选择1997年7月至2003年6月于中山眼科中心就诊的32例穿透性角膜移植术后创口裂开的患者,根据眼球裂伤程度采用创口缝合或联合虹膜切除、晶状体切除、人工晶状体摘出、前段玻璃体切除、同期或Ⅱ期玻璃体切除或联合眼内气体和硅油填充视网膜脱离复位术等处理创口裂开及其并发症,随访观察术后视力、植片透明度、眼压及眼球后段结构的变化.结果术后24例患者保留了眼球,8例患者眼球萎缩.8例缝线断裂或松脱患者,术后6例视力提高,角膜植片均透明,眼压正常,未出现玻璃体出血及脉络膜、视网膜脱离.14例创口裂伤范围1/4～1/2周的患者,术后8例视力下降,11例角膜植片混浊,5例眼压异常（降低或升高）.8例创口裂伤范围1/2～3/4周患者,术后7例视力下降,5例角膜植片混浊,7例眼压异常（降低或升高）,4例玻璃体出血,4例脉络膜、视网膜脱离.2例创口裂伤范围≥3/4周的患者,术后均无光感,角膜植片混浊,眼压降低（眼球萎缩）,出现玻璃体出血及脉络膜、视网膜脱离.结论穿透性角膜移植术后创口稳定性和抗张能力差,较小的外力打击可引起破裂.穿透性角膜移植术后外伤性创口裂开常合并更严重的眼内容物脱出、玻璃体出血或脉络膜视网膜脱离,比普通眼外伤程度更严重、预后更差.     

1997至2002年山东省眼科研究所穿透性角膜移植术的原因分析

目的 探讨1997至2002年山东省眼科研究所6年间行穿透性角膜移植术（PKP）的原因及其变化。方法 对1997年1月至2002年12月山东省眼科研究所的所有PKP病例进行回顾性调查,将PKP的原因分为10类：化脓性角膜炎、单纯疱疹病毒性角膜炎、圆锥角膜、大泡性角膜病变、角膜白斑、角膜破裂伤、角膜烧伤、再次PKP、遗传相关的角膜营养不良和角膜变性及其他。并且记录化脓性角膜炎的病原菌,大泡性角膜病变的病因,再次PKP的原发病和再次手术的原因。分析6年间PKP的原因及其变化情况。结果 共调查1702例PKP患者。PKP的原因依次是化脓性角膜炎542例（31．9％）、单纯疱疹病毒性角膜炎299例（17．6％）、圆锥角膜219例（12．9％）、角膜白斑164例（9．6％）、大泡性角膜病变118例（6．9％）、角膜破裂伤105例（6．2％）、再次PKP77例（4．5％）、角膜烧伤70例（4．1％）、遗传相关的角膜营养不良和角膜变性67例（3．9％）及其他41例（2．4％）。圆锥角膜（χ^2=26．399,P〈0．001）和大泡性角膜病变（χ^2=11．4229,P〈0．001）所占比例呈明显上升趋势,其他原因则无明显变化。化脓性角膜炎中真菌感染居首位（65．9％）,6年来各病原菌所占比例无明显变化。多数大泡性角膜病变患者有内眼手术史,其中白内障手术最常见（76．3％）。再次PKP的原发病以角膜烧伤（24．7％）、单纯疱疹病毒性角膜炎（23．4％）及化脓性角膜炎（14．3％）为主,再次手术的原因主要是免疫排斥（61．0％）、植片感染（14．3％）及单纯疱疹病毒性角膜炎复发（10．4％）。结论 感染性角膜病仍然是PKP的主要适应证,其中真菌感染为首位病因。圆锥角膜和大泡性角膜病变均呈明显上升趋势。（中华眼科杂志,2006,42：704-708）     

Spontaneous wound dehiscence after removal of single continuous penetrating keratoplasty suture

PURPOSE: To determine the incidence and complications of spontaneous wound dehiscence after removal of a single continuous penetrating keratoplasty (PK) suture. DESIGN: Retrospective consecutive, noncomparative interventional case series. METHODS: Retrospective review of 324 consecutive continuous suture PKs performed between 1992 and 1999. RESULTS: Sixty-nine (21.3%) of 324 PKs reviewed had the continuous suture removed. The average interval for suture removal after PK was 24.5 +/- 15 months (range, 2.8-63.3 months). Five of the 69 eyes (7.2%) developed spontaneous wound dehiscence without direct eye trauma. In the five eyes that developed wound dehiscence, the continuous suture was removed at 24.6 +/- 10.3 months (range, 14-42 months). Dehiscence occurred at 11.6 +/- 6.5 (range, 3-18) days after suture removal. Significant history associated with wound dehiscence included coughing, yawning, falling without trauma to the eye, and spontaneous wound separation. The reasons for suture removal were astigmatism in four of five (80%) patients and a broken suture in one of the five patients. In four of five (80%) patients, the location of wound dehiscence correlated with the steep axis of corneal keratometry before suture removal. Surgical intervention preserved the presuture removal best-corrected visual acuity in four of the five eyes. No eyes with an intact suture spontaneously dehisced. CONCLUSIONS: The rate of spontaneous wound dehiscence after removal of a continuous suture in our series was 7.2%. All spontaneous dehiscences occurred within 2 weeks after suture removal. Older patients, who had PK for corneal edema with postoperative astigmatism and have been using corticosteroids drops for prolonged periods of time, are at higher risk of wound dehiscence. Patients should be monitored closely during the first 2 weeks after removal of a continuous suture for signs of wound separation, especially when suture removal is performed for astigmatism. Patients should be cautioned about the risk and symptoms of wound dehiscence before suture removal to facilitate early recognition and intervention for preservation of best visual potential.     

Spontaneous wound dehiscence after removal of single continuous penetrating keratoplasty suture: conservative management

PURPOSE: To describe a case of spontaneous wound dehiscence (WD) following removal of single continuous penetrating keratoplasty (PKP) suture, who was treated conservatively with a bandage contact lens. METHODS: A 36 year-old man who had penetrating keratoplasty for keratoconus 15 months earlier and removal of the single continues suture the previous week underwent ocular examination. He was treated with topical dexamethasone 0.3%, chloramphenicol 0.5% and cyclopentolate 1% 3 times a day and had a bandage contact lens (BCL) inserted. RESULTS: On presentation, he was complaining of reduced vision, tearing and pain following an attack of rhinitis-induced sneezing. His visual acuity (VA) in the affected eye was counting fingers, the anterior chamber was formed, the intraocular pressure (IOP) was low and there was a 2-clock-hour WD with a positive Seidel test but no iris incarceration. Two months later, his corrected VA was 6/5, his IOP was normal and the graft-host junction was good with no uplift. CONCLUSIONS: A 2-clock-hour WD after single continuous PKP suture removal may be conservatively treated with a BCL.     

穿透性角膜移植术临床分析

目的 探讨穿透性角膜移植的主要病因、疗效和并发症.方法 对96例(97只眼)穿透性角膜移植进行回顾性研究,随访0.5～5年.结果 (1)病因:角膜白斑41只眼(42.3%),单纯疱疹病毒性角膜炎28只眼(28.9%),角膜溃疡16只眼(16.7%),圆锥角膜4只限(4.1%),大泡性角膜病变8只眼(8.2%).(2)疗效:角膜植片透明81只眼(83.5%),视力0.05以下7只眼(7.2%),0.05～0.2者53只眼(54.6%),0.3～0.5者28只眼(28.9%),0.5以上者9只眼(9.3%).(3)并发症:主要为角膜免疫排斥反应(8只眼)和继发性青光眼(4只眼).结论 穿透性角膜移植术是治疗角膜致盲性眼病的有效方法.     

穿透性角膜移植术128例临床分析

目的评价穿透性角膜移植术治疗角膜疾病的疗效。方法对128例(128眼)角膜混浊病人行穿透性角膜移植术,于术后1月、3月、6月、12月、24月观察角膜的透明情况以及并发症。结果穿透性角膜移植术后1月128眼中82眼透明(64.1%),术后6月90眼中69眼透明(76.7%),术后12月84眼中53眼透明(63.1%),术后24月43眼中27眼透明(62.8%)。以此同时,患者的视力均有不同程度的增加,术后1月角膜透明82眼中有67眼矫正视力大于0.1(82%),术后3月63眼中有59眼矫正视力大于0.1(94%)同,术后6月69眼中有66眼矫正视力大于0.1(96%)。结论穿透性角膜移植术是治疗因角膜病致盲患者的重要手段,排斥反应是术后主要并发症,三联手术安全有效。     

PKP术后急性内皮型免疫排斥反应发生的时间规律

目的：回顾性总结穿透性角膜移植术（penetrating keratoplasty,PKP)后急性内皮型免疫排斥反应发生的时间规律。方法：对我院6年来实施的PKP病例进行回顾性分析，对发生过急性内皮型免疫排斥反应的256例病例，详细总结免疫排斥反应发生的时间、次数，以及性的原因、预后等。结果：76.53%(196/256）的首次排斥反应发生在术后1年内，19.14%（49/256）发生在术后2年内，只有11例发生在2年以后。二次排斥距首次排斥的时间1-16.5个月，平均4.8个月。真菌性角膜炎病例的排斥性时间相对较提前，73.8%(62/84)集中在术后8个月内，其中全角膜移植者多发生在术后2周内。HSK病例在术后6-9个月份和13-17个月各有一个高峰。细菌性角膜溃疡病例发生的较分散，但是主要集中在3-11个月之间。结论：掌握这些规律对临床治疗和研究具有重要指导意义。     

Infectious keratitis after astigmatic keratotomy in penetrating keratoplasty: review of three cases

PURPOSE: To present 3 cases in 2 patients of infectious keratitis of the astigmatic keratotomy (AK) site in patients who had previous penetrating keratoplasty. METHODS: History, clinical examination, chart review, cultures, and laboratory results were obtained from 2 patients with infectious keratitis within the donor stroma of their graft after an AK was performed. RESULTS: One patient had an early infiltrate of the AK site that was culture negative. This cleared with fortified antibiotics, and the patient had a final visual acuity of 20/30-2. The second patient developed 2 late infections, the first with coagulase negative Staphylococcus and the second infection with Pseudomonas aeruginosa. Both of these infections cleared with fortified antibiotics, and the final visual acuity was 20/25. Neither patient developed a rejection episode from the infections, and both grafts survived. CONCLUSIONS: We report a series of 3 cases of infectious keratitis in 2 patients after AKs in corneal grafts. This, to the best of our knowledge, has not been previously reported. Patients who suffer infectious keratitis after AK in corneal grafts may have good visual outcomes if managed with appropriate antibiotic regimens and closely followed.     

A case of recipient bed melt and wound dehiscence after penetrating keratoplasty and subconjunctival injection of bevacizumab

ABSTRACT:: We describe a case of recipient bed melt and wound dehiscence after uneventful penetrating keratoplasty and subconjunctival injection of bevacizumab. Three weeks postoperatively, the patient presented with limbal ischemia, recipient bed melt, and wound dehiscence corresponding to the area of bevacizumab injection. The melt was managed by application of cyanoacrylate glue along with bandage contact lens. Although the graft survived, there was a problem in re-epithelization. This case highlights the need for further studies to elucidate the therapeutic dose, side effects, and correct timing of using bevacizumab with respect to corneal transplant surgery.