|Year : 2007 | Volume
| Issue : 1 | Page : 43-47
First report of evaluation of K-M media: A new corneal preservation medium
Beena M Desai1, BM Khamar2, BK Ghodadra1
1 M and J Institute of Ophthalmology, Ahmedabad, India
2 KM School of PG Medicine, Ahmedabad, India
|Date of Submission||22-Jan-2006|
|Date of Acceptance||31-Oct-2006|
Beena M Desai
B/2, Abhishek Apartment, Haritej Society, Opposite ATIRA and AMA, Ahmedabad
Source of Support: None, Conflict of Interest: None
Purpose: To analyze the outcome of keratoplasty performed using Kalevar-Majumdar (K-M) media, a new synthetic viscous medium for preservation of the cornea.
Materials and Methods: The K-M media-preserved donor eye balls were kept in a bottle in a refrigerator at 4° C till the corneas were used. Forty-eight consecutive keratoplasty cases of pseudophakic bullous keratopathy with vision less than counting fingers at one meter and operated by a single surgeon have been analyzed. Corneal donor button of 7.5 mm was used on the 7.0 mm recipient bed in all cases. Surgery was done with a standard technique. All the cases were examined daily for the first week and at the end of one month for graft clarity, epithelial defect and stromal edema.
Results: The K-M media-preserved corneal grafts remained clear at the end of the first week in 95.8% (46 of 48) cases and at the end of one month in 93.7% (45 of 48) cases. Donor epithelial haze cleared in 24h in all cases. The stromal edema got cleared in the majority (91.7%, 44 of 48) within 24h. Epithelial defect was seen in only 10.4% (five cases). There was no primary graft failure.
Conclusion: K-M medium, a new viscous, synthetic corneal preservation medium, is a safe (no primary donor failure) alternative to conventional liquid corneal preservation media. K-M media-preserved eyes appear to have better preserved corneal epithelium with faster achievement of graft clarity postoperatively.
Keywords: Corneal preservation media, donor cornea, Kalevar-Majumdar medium, moist chamber, pseudophakic bullous keratopathy
|How to cite this article:|
Desai BM, Khamar B M, Ghodadra B K. First report of evaluation of K-M media: A new corneal preservation medium. Indian J Ophthalmol 2007;55:43-7
|How to cite this URL:|
Desai BM, Khamar B M, Ghodadra B K. First report of evaluation of K-M media: A new corneal preservation medium. Indian J Ophthalmol [serial online] 2007 [cited 2019 Oct 17];55:43-7. Available from: http://www.ijo.in/text.asp?2007/55/1/43/29494
Corneal preservative medium has been the subject of constant research. The purpose of research has been to increase the yield of received donor eyes and to extend the window period for media-preserved donor eye. The need for better methods of corneal preservation led to the development of the McCarey-Kaufman (M-K) medium in 1974. This was followed by a series of other liquid corneal storage media like Optisol-GS, K-Sol, Likorol and Chen medium. All are widely used and accepted for corneal preservation. A longer period of corneal storage with these media, compared to moist chamber preservation has allowed a flexible surgical scheduling which is often required for the donor material evaluation, blood testing and transportation of donor tissue as well as reporting of recipient to the hospital. Use of all of the above media requires skilled staff and a better infrastructure for removal of corneo-scleral rim. Liquid storage media contain fetal bovine serum and have a risk of transmitting prion-mediated diseases like bovine spongiform encephalopathy. All media have a cell culture medium at its base, however, corneal preservation is not associated with the growth of any corneal cells (endothelial or epithelial.) The purpose of a corneal storage medium is to preserve it for as long a time as possible. The sudden arrest of aqueous humor formation after death leads to the depletion of nutrients and oxygen supply to the eye. This results in damage to the corneal cells by autolysis. This damage is temperature-dependent and can be minimized by storing at a lower temperature up to four degree centigrade.,
Kalevar-Majumdar (K-M) medium is the first synthetic medium which does not use amino acid and bovine serum. It contains balanced salt solution, sodium carbonate (3.51 mg/ml), glucose (10.0 mg/ml), methyl cellulose (20.0 mg/ml) with pH adjusted to 7.4. Use of methyl cellulose makes it viscous . It does not contain antibiotics, dextran or any other hyper-osmotic agent. K-M medium has been developed over two decades and has been evaluated in vitro and in vivo by Kalevar, Dhanda, Vyas, Khamar. (Personal communication). This differs from other media in its preservation technique also. In the K-M medium preservation technique, aqueous humor is replaced with viscous K-M medium, by injecting it into the anterior chamber, and the whole eyeball is preserved in a moist chamber at four to eight degrees centigrade. In this technique, only the endothelial side is exposed to the corneal storage medium. In conventional liquid storage media the whole corneo-scleral rim is immersed into it. Donor corneas preserved using the K-M medium have been used by many corneal surgeons since 1995 including the authors. The authors (BMD, BKG) have gradually increased its use and since 2003 have used K-M preserved corneas exclusively. However, there is no published data on the surgical outcome using K-M preserved corneas. The aim of the study was to analyze the records of 48 consecutive K-M media-preserved corneal transplantations to determine the safety and efficacy of the K-M medium, a new viscous corneal storage medium.
| Materials and Methods|| |
Of 250 consecutive penetrating keratoplasties performed using K-M medium-preserved corneas at the M and J institute of ophthalmology, Ahmedabad, 48 consecutive cases of pseudophakic bullous keratopathy (PBK) by a single surgeon (BMD) were selected for the retrospective study. All corneal transplants were performed following the ethical guidelines for biomedical research on human subjects issued by the Indian Council of Medical Research in 2000. The Institutional Ethical Committee had cleared the project. All the patients had given their informed consent. K-M media prepared by Cadilla Pharmaceuticals Limited, Ahmedabad were procured from Red Cross Eye Bank, Dholka, Dist. Ahmedabad. Donor eyes received either from the Red Cross Eye Bank Dholka, Dist. Ahmedabad or at the D. E. Anklesharia Eye Bank (attached to M and J institute of ophthalmology) were used. After evaluation of the donor corneas at the eye bank, eyeballs with viable corneas were disinfected with gentamycin and subsequently with 5% povidone iodine. K-M medium was injected in the anterior chamber through the limbus with 26-G needle with all aseptic precautions, between two to eight hours of receiving the donor eyes in to the eye-bank. The K-M media-preserved donor eye balls were kept in a moist chamber and preserved at four to eight degrees centigrade. Detailed information including (1) donor age (2) death-enucleation time (3) death-preservation time (D-P interval), (4) death-surgery time (D-S interval) and (5) surgical time were recorded. All the donor eyes were evaluated for epithelial haze and edema on slit-lamp biomicroscope prior to surgery. All the patients were operated between June 2003 and August 2005 under peribulbar anesthesia. Prior to surgery donor eye ball was dipped in normal saline for 10 min which contains 0.3% gentamycin. The 7.5 mm graft size was used in all cases and transplanted over 7.0 mm recipient bed. Donor button was taken from the epithelial side. Of 48 eyes donor epithelium was removed intraoperatively in four eyes, out of which D-S interval was > 36h in three eyes and one eye had D-S interval of 18h. Recipient bed was prepared by centering a disposable trephine and a partial thickness incision was made at about 50 to 80% depth. The anterior chamber was entered with a No. 11 Bard Parker blade and the excision of the recipient tissue was completed with corneal scissors. The intraocular lens (IOL) was explanted in patients with anterior chamber IOL. Anterior chamber was maintained throughout the surgery with viscoelastic. Sixteen interrupted sutures were taken with 10/0 nylon suture. Viscoelastic was replaced by air and normal saline leaving a tiny air bubble in the anterior chamber. Sub-conjunctival injection of gentamycin and dexamethasone was given at the end of the surgery. All cases received topical dexamethasone and chloramphenicol (U-col -c by Univision or Decol-c by Intas pharmaceuticals) eye drops four times a day beginning first postoperative day. Timolol 0.5% (Iotim by FDC) eye drops twice a day and lubricant ointment (Lacrygel eye ointment by Sunways) at bedtime was used for one month. Hyperosmotic agents (Hypersol 0.5% by Java pharmaceuticals) were added in cases that showed postoperative corneal edema till edema got cleared. All the cases were examined on slit-lamp daily for the first week and at the end of one month. Besides general evaluation attention was paid to the graft for its clarity, epithelial condition and stromal edema. Graft clarity was defined as the absence of stromal or epithelial edema on slit-lamp examination. Smallest break in epithelial continuity was taken as epithelial defect. Stromal edema was defined as mild increase in corneal thickness with slight haziness in stroma and few folds, but with good visibility of endothelium. Donor failure refers to graft edema present within the first 24h after penetrating keratoplasty that persists in spite of maximal medical therapy in absence of obvious cause.
| Results|| |
There were 33 male and 15 female patients (M: F= 2.2:1). The age of the patients ranged from 14 to 85 years, the mean age was 61 years (SD=12.1) and the median age was 64 years. The age of donor eyes ranged from 14 to 74 years, the mean age was 49.2 years (SD=13.9) and the median age was 53.5 years. Thirty-eight donor eyes were of < 60 years and 10 donor eyes were > 60 years. The interval between death and enucleation ranged from two to six hours, the mean interval was 4.5h (SD = 1.5). The D-P interval ranged from eight to 14h. The D-S interval ranged from 12 to 58h, mean storage interval was 28.4h (SD = 11.26), median storage interval was 28h. Surgical time ranged from 45 to 60 min. Out of 48 PBK cases, 41 had posterior chamber IOL and seven had anterior chamber IOL.
Preoperative donor cornea evaluation showed epithelial haze in 28 corneas (58.3%), all had storage interval more than 24h irrespective of donor age [Table - 1]. None had an epithelial defect. Preoperative stromal edema was found in nine donor corneas (18.7%). Out of these nine cases of stromal edema, two had storage interval < 24h, one had 24-36h and six had > 36h. Preoperative stromal edema in donor eye was correlated with age, seven of nine having donor age more than 50 years. It was also correlated with D-S interval, six of nine having D-S interval more than 36h [Table - 2].
On the first postoperative day, corneal graft was found to be clear in 81.3% (39 cases). Epithelial defect was seen in 10.4% (five cases). Of the 28 corneas with preoperative epithelial haze only two developed epithelial defect. Epithelial defect healed in all five cases on first week follow-up. All epithelial defects were seen with donor age of more than 60 years. Three of five cases had D-S interval less than 24h [Table - 1].
Stromal edema was detected in 8.3% (four cases). Out of nine cases of preoperative corneal edema, five had clear corneas on the first postoperative day [Table - 2]. Of four cases with mild stromal edema on first postoperative day, two cleared subsequently. The other two cases had raised intraocular pressure (IOP) which persisted till the end of follow-up. Both had explantation of anterior chamber IOL with anterior vitrectomy. Both had D-S interval <24h. Endophthalmitis developed in one of them on the third day. Graft clarity on first postoperative day and on subsequent follow-up were not proportional to storage interval [Table - 3].The percentage of graft clarity, epithelial defect and stromal edema at the end of the first week was 95.8% (46 cases), nil and 4.2% (two cases) respectively. At the end of one month the clear graft was seen in 93.7% (45 cases). One more patient with a clear graft at one week developed epithelial defect at one month [Figure - 1]. No donor failure (primary graft failure) was seen in this series which had longest D-S interval of up to 58h.
| Discussion|| |
Initially K-M media-preserved cornea was used only for therapeutic keratoplasty by us. With gaining confidence we have made it routine for our corneal storage. In the present study the graft was clear in 93.7% (45 of 48 cases) at the end of one month. Reported percentages of clear graft with different storage media range from 75.3% to 93%.,, The reported studies for clear graft in pseudophakic bullous keratopathy vary from 66.6 to 95%.,,, This study documents outcome for corneas stored using the K-M medium for the first time to our knowledge. The K-M medium is the first synthetic medium which does not contain fetal bovine serum. As it does not contain bovine serum there is no risk of bovine spongiform encephalopathy. This has been a concern of late. Recently, a new corneal storage medium (Eurosol) is evaluated, which contains all constituents of conventional liquid corneal storage media except fetal bovine serum. The K-M medium also does not contain amino acids seen in all liquid corneal storage media. In spite of this it maintains the integrity of the cornea. Since K-M medium storage allows moist chamber preservation, the demands for skill for preservation and infrastructure are significantly reduced. It also allows terminal disinfection of donor corneas which is not possible with the currently available liquid corneal storage media. Many corneal surgeons believe that corneas from younger donors are preferable to those from older donors because of higher endothelial cell count in younger corneas., Many previous studies have been unable to correlate donor age with corneal graft success.,, However, donor age higher than 70 years may increase the risk of graft failure. In our study donor eyes up to 74 years of age had good outcome. In our study preoperative epithelial haze, observed in 28 donor cornea, was directly related to D-S interval. This is identical to the findings of liquid corneal storage media in which the medium bathes the whole of the cornea.,
In the present study intact graft epithelium on the first postoperative day was found in 89.6% (43 cases). The reported figures for intact graft epithelium on the first postoperative day for liquid storage media vary from 65% to 0.0%., All the five cases with epithelial defect on the first postoperative day, had donor age more than 60 years. The D-S interval was less than 24h in three and more than 24h in two cases. All epithelial defects cleared at the end of one week with a median of two days. Corneal epithelialization was achieved in all (100%) cases at the end of one week. With liquid storage media like Chen and Optisol complete epithelialization is seen in 88% at the end of one week while it was found to be 12 days with median of two days for M-K medium. In cryo-preserved cornea it took three to five days for epithelial healing. The better epithelial integrity seen in this series may be due to the fact that the epithelium is not immersed in the corneal storage medium when using K-M storage medium. None of the donor corneas had epithelial defect preoperatively. It is known that following corneal transplant, eyes with preexisting epithelial defect take a longer time to recover., Analyzing the relation of donor age, K-M media storage interval and postoperative epithelial defect, we observed that the postoperative epithelial defect was higher in elderly donors but had no correlation with storage interval . The storage duration is a significant risk factor for development of postoperative epithelial defect when corneas are stored using liquid storage media. Fewer epithelial abnormalities were observed with shorter D-P interval. Preoperative stromal edema (nine donor corneas) was observed to be proportional to the D-S interval. However, the D-S interval did not affect the final outcome of graft clarity. We observed no difference between grafts transplanted within a few hours after the death of the donor and at 58h of preservation. As D-P interval decreased, lower frequency of stromal edema and descemet folds was observed. In our study four cases (8.33%) had stromal edema on the first postoperative day. Out of four cases three had donor age <60 and one had >60 years. The D-S interval was <24h in two cases and > 36h in two cases. The stromal edema cleared postoperatively within one week (in two cases with D-S interval >36h.). In cryo-preserved cornea it took two to three weeks for clearance of stromal edema. Intraoperative corneal thickness assessed clinically showed slight increase with the increase in D-S interval. This has also been observed with other storage medium. We did not find any correlation between postoperative stromal edema and donor age or D-S interval. The present study as well as the study with the M-K medium found no effect of corneal storage variable on corneal graft success. Primary graft failure is seen in up to 4.3% of corneal graft with liquid storage media in spite of all advances in evaluation.,,,,,,,,, It is not associated with any donor or storage condition. In our study, at the end of one week, two grafts were not clear. One patient developed endophthalmitis (D-S interval 24h and donor age 53 years); the second patient had persistent corneal edema due to rise of IOP (D-S interval 20h, donor age 63 years). At the end of one month the graft was not clear in one more case due to reappearance of epithelial defect in the follow-up period. All the three cases had obvious reasons for graft conditions. Thus we had no primary donor failure in our study. The increased average time from donor death to surgery for K-Sol (56h) and M-K (40h) corneas compared with moist chamber corneas (15h) facilitated the scheduling of surgery at the cost of increased chance of primary graft failure. In the present study endophthalmitis developed in one (2.08%) case, a 65-year-old male diabetic patient, on the third day. He had PBK with anterior chamber IOL. During surgery IOL was explanted and anterior vitrectromy was done. Endophthalmitis was managed by intra-vitreal cephazolin, gentamicin and dexamethasone. Vitreous tap culture was negative for organisms. Infection was controlled but graft edema persisted. Culture of the K-M medium did not grow any organism. The reported figures of endophthalmitis in different studies are 0.2%, 2.4%, 0.1%.,,(37)
Lack of endothelial evaluation by specular microscopy and lack of head to head comparison with other storage media may be considered as limitations of the present study. A prospective study comparing different storage media is underway.
| Conclusion|| |
The K-M medium is a viscous corneal preservative medium. The K-M medium, a moist chamber preservation technique, is a safe (no primary donor failure) alternative to conventional liquid corneal preservation media. K-M media-preserved eyes have better preserved corneal epithelium and are associated with faster achievement of graft clarity.
| Acknowledgments|| |
We are thankful to late Dr. R. P. Dhanda and, Dr. V. Kalevar for their support during development of the K-M medium. A large part of the developmental work was done in the laboratory of Dr. U. M. Raval of the Dept. of Zoology beginning with the making of the M-K medium in 1978. During the later part of development Dr. U.H. Vyas played a critical role in conducting the experiments. Dr. B. C. Lavingia provided all support during the clinical evaluation of the K-M medium at M. and J. Institute of Ophthalmology. Mr. Gautambhai Majumdar and Harshil Majumdar (Red Cross Eye Bank, Dholka, Gujarat) has helped in the development and use of the K-M medium. The technology to manufacture the K-M medium is transferred to Cadila Pharmaceutical Ltd. (Ahmedabad) who has provided the K-M media.
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[Figure - 1]
[Table - 1], [Table - 2], [Table - 3]