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ARTICLE
Year : 1964  |  Volume : 12  |  Issue : 2  |  Page : 85-90

Corneal grafting in vascularised cornea particularly in trachomatous eyes


Corneal Surgery Unit and the Regional Eye-Bank, Indore, India

Date of Web Publication14-Feb-2008

Correspondence Address:
R P Dhanda
Corneal Surgery Unit and the Regional Eye-Bank, Indore
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Dhanda R P, Kalevar V K. Corneal grafting in vascularised cornea particularly in trachomatous eyes. Indian J Ophthalmol 1964;12:85-90

How to cite this URL:
Dhanda R P, Kalevar V K. Corneal grafting in vascularised cornea particularly in trachomatous eyes. Indian J Ophthalmol [serial online] 1964 [cited 2020 Dec 3];12:85-90. Available from: https://www.ijo.in/text.asp?1964/12/2/85/39082

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Trachoma by virtue of being asso­ciated with vascular changes in and round the cornea has long been con­sidered a disadvantage for kerato­plasty in trachomatous circumstances. The observations made here are from a series of corneal grafts on 86 tracho­matous recepients out of a total of 240 operations on 216 eyes.

From the reports of the recent na­tional survey for the incidence of tra­choma it has been established that trachoma directly or indirectly is the one biggest single cause responsible for the heavy incidence of corneal blind­ness in India specially in children.

Madhya Pradesh with an incidence of 41.3%, has Trachoma as a problem of significance.

In a series of 500 cases referred for keratoplasty, 214 (42.8%) had tra­choma of which 27.1% were in active stage, 55.1 % in healed and 17.8% in complicated stage. Similarly, of the 216 operated eyes (24 being retrans­plants)), 86 (39.8%) had trachoma of which 27.9% were in active stage, 51.2% in healed and 20.9% in compli­cated stage. This series is therefore fairly representative of trachomatous circumstances and of the practice of corneal grafting in vascularised cor­neas.

Corneal vascularisation, we all know can be of non-trachomatous or tracho­matous etiology. 98 out of 216 eyes operated in this series, 45.4%, had dis­tinct vascularisation of the recepient cornea, 45.9% of which being of tra­chomatous origin. The remaining 54.1 % included 11 cases of chemical burns and 16 cases of long standing degene­rate conditions like total leucoma adherens, partial and total anterior staphylomata.

This corneal pathology associated with vascularisation is further compli­cated in some cases by secondary changes in the conjunctival and the corneal epithelium like xerosis, symble­pharon etc., thereby becoming an im­portant consideration in the assessment of indications and prognosis of corneal grafting.

Vascularisation has a disadvantage that the blood vessels carry large doses of antibodies to the otherwise avascular donor corneal grafts and therefore add to the incidence of graft disease. This factor is further supported by the grea­ter incidence of graft failures with post­operative anterior synechia not because the anterior synechia clouds the graft but the vascularity of the uveal tissue provides the antibody material.-Mau­manee (1962).

Vascularisation of the cornea has another important consideration in corneal surgery. Blood vessels have a tendency to readily extend in-between the recepient cornea and the lamellar graft thereby laying down fibrous ele­ment and impairing vision. It is in­teresting to note that a full thickness graft resists invasion by vessels which may at the most extend upto and along its margin without affecting its clarity. They may rarely extend, on to the posterior surface. The suggestion therefore is that for vascular corneas, a penetrating graft with recession of conjunctiva or pseudo-pterygium and diathermy of blood vessels at the time of operation should be the choice as primary surgery (Hughes). Any ves­sels which reappear after the operation are usually small and being new can be successfully treated by β-radiation. Some suggest, small vascularisation may even be desirable. De Voe (1963)


  Histo-Pathological Studies of Trachomatous and Vascular Corneas Top


Diseased corneas removed from re­cepient eyes provided an interesting material for histo-pathological studies.

From an intial study of over a 100 corneal buttons some interesting obser­vations on trachomatous and vascular corneas are being reported.

Hyper- and parakeratosis, epithelial dysplasia and hyper-plasia in tracho­matous corneas with secondary xerosis have been characteristically noted. A droplet type degenerative change observed in lamellar layers of the corneas of complicated trachoma has been a very interesting observation and awaits further analysis.

Alkalies like ammonia and caustic soda, sulphuric acid, sulphur dioxide and garlic were responsible for gross and vascular pathology in cornea in 12 cases for which corneal surgery was done. These corneal buttons have pro­vided another group of interesting histo-pathological findings. Marked hyperplasia and newly formed super­ficial and deep vascular channels ade­quately confirm the extremely poor prognosis of keratoplasty in chemical burns, also reported in literature-­Hughes (1963).

Following are a few of the charac­teristic histopathological findings:-


  Pre-Operative and Operative Considerations Top


Apart from specific local anti-tra­choma therapy for three weeks in active cases, in every case of vascularisation of some degree, a real deep peritomy preferably a week before grafting is an essential pre-requisite. Bigger blood vessels on the sclera are cauteris­ed and smaller ones near the limbus treated with Hildreth. Thio-Tepa, (Cynamide) has been suggested as an effective drug for control of vasculari­sation by virtue of its property of in­hibiting proliferation of endothelial cells and thereby preventing new ca­pillary formation.Rock (1963).

Friability of the trachomatous and vascularised corneas is an important factor, particularly during lamellar dis­section and stitching of the graft. In a thin dissection of 0.3 mm. or less, there is a tendency for tearing of the rece­pient corneal button. The depth of dissection in such cases should there­fore not be less than 0.4 to 0.5 mm. to reduce chances of buttonholing. A tra­chomatous cornea is relatively thicker unless it is associated with corneal ectasia in which cases of course the choice is penetrating surgery and not lamellar grafting. The bite in the tissue while stitching the graft, however, should be relatively deeper to prevent cutting through the friable superficial lamellae of a vascular cornea.

Evidence of trachomatous scarring should be pointedly looked for in the donor eyes also. The eye in a dead body having become avascular, it is not always easy to identify trachoma­tous pathology except in grossly scarr­ed lids. Herbert's pits and corneal haze extending intralimbal can however be seen in proper illumination even in an enucleated eye. This scarred area should therefore be specifically exclud­ed from the donor button.


  Post-Operative Complications Top


An analysis of the post-operative complications in trachomatous and non-trachomatous series is interesting. Of the 140 penetrating grafts 49 were on trachomatous eyes and 91 on non­trachomatous eyes. The significant difference in the markedly higher inci­dence of ectasia in trachomatous cases is due to premature falling off of stitches which is more frequent in soft friable vascular corneas.

In the lamellar series, a markedly higher incidence of ulcer complication is again distinctly due to trachomatous pathology. Vascularisation, as expect­ed, is relatively more frequent both in penetrating and lamellar surgery.

Ectasia, vascularisation and ulcers therefore, could be considered post­operative complications directly related to trachomatocs pathology in the rece­pient eye.

Epithelial ulcer is an intractable complication and because of deficient metabolic state of the graft, takes a long time to heal. Superficial vascula­risation usually readily responds to therapy, but in complicated trachoma and heavily vascularised corneas of chemical burns however, although the graft in early stages appears clear, fleshy vascularised tissue may invade it later on and ruin the chances of re­covery.


  Results Top


With all that has been said above, it should be natural to compare the final results of corneal grafting in tracho­matous and non-trachomatous cases.

From a study of this table it may be noted that results of surgery in non­trachomatous cases and in cases asso­ciated with trachoma in stages I-IV are not appreciably different but com­plicated trachoma is however a differ­ent problem. The successful results in lamellar surgery from 88.9% in non­trachomatous and 73.4% in trachoma­tous (I-IV) eyes are markedly reduced to 43.7%, in complicated trachoma. Penetrating surgery is of course not to be attempted in eyes grossly compli­cated by trachoma.

It should be correct to infer there­fore that except in complicated stage, trachoma is a consideration but not a contraindication for corneal grafting in India.

The two complications peculiar of corneal surgery in trachoma are:

1) premature falling of stitches, with a consequent higher incidence of ectasia,

2) a higher incidence of ulcers in the lamellar series.[5]


  Acknowledgement Top


We are grateful to the Indian Coun­cil of Medical Research and the Na­tional Council to Combat Blindness Inc., New York for their substantial help to enable us to undertake newer aspects of study and research.

Dr. M. M. Arora, Professor of Pa­thology, M. G. M. Medical College, Indore and Dr. D. N. Gupta, Professor of Pathology, Maulana Azad Medical College, New Delhi have given valu­able guidance in histo-pathological studies. We are thankful to Dr. U. C. Gupta, Director, T.C.P.P. for providing useful data.

 
  References Top

1.
DeVoe, A. G. (1963) Arch. Ophth. 70: 737-738 (Editorial).  Back to cited text no. 1
    
2.
Dhanda, R. P. (1963) Amer. J. Ophth. 55: 1217-1219.  Back to cited text no. 2
    
3.
Hughes, W.F. (1963) Trans. Am. Acad. Ophthal. & Ots. 67: 292-319.  Back to cited text no. 3
    
4.
Maumenee, A. E. (1962) Personal com­munication.  Back to cited text no. 4
    
5.
Rock, R. L. (1963) Arch. Ophth. 69: 330-334.  Back to cited text no. 5
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
 
 
    Tables

  [Table - 1], [Table - 2]



 

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Post-Operative C...
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Acknowledgement
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