|Year : 1983 | Volume
| Issue : 5 | Page : 603-606
Post-keratoplasty non-formation of anterior chamber
Madan Mohan, JS Saini, G Mukherjee
Dr. Rajendra Prasad Centre for Ophthalmic Sciences A.I.I.M.S., New Delhi, India
Dr. Rajendra Prasad Centre for Ophthalmic Sciences A.I.I.M.S., New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mohan M, Saini J S, Mukherjee G. Post-keratoplasty non-formation of anterior chamber. Indian J Ophthalmol 1983;31:603-6
The non formation of anterior chamber or loss of anterior chamber following penetrating keratoplasty has great bearing on the graft prognosis. Despite several refinements in technique of surgery and availability of better suture materials and instruments, maintaining normal depth of anterior chamber is still problematic ,, specially in countries like ours  where indications for keratoplasty are different from those in the West. 
In this study an analysis of causes and management of the problems of maintaining anterior chamber depth following penetrating 'Grafts is presented.
| Materials and Methods|| |
734 consecutive penetrating grafts done at this hospital form the subjects of this retrospective study. Non-formation of normal depth of anterior chamber following keratoplasty was seen in 108 eyes. A total of 84 eyes following 395 therapeutic grafts had non formation of anterior chamber while only 24 eyes had similar problem following 339 optical grafts. Meticulous examination was made in each case to detect the likely cause and then appropriate management was done. 608 cases had P.K. alone while 126 cases had combined procedure of trabeculectomy and P.K. either in one stage or two stages.
| Observations|| |
Non formation of A.C. was observed in 79 cases (21.8%) following 361 therapeutic grafts while only 5 cases (14.7%) had this complication when combined procedure was undertaken in another 34 eyes. Among the optical grafts 17 eyes (6.9%) had non formation of A.C. following P.K. done and 7 cases (6.7%) had it following combined procedure [Table - 1]. Majority of grafts were larger than 9 mm [Table - 2]. 80% of cases were seen during the first week following P.K. alone while 91.7% were seen during the same post-operative period following combined procedure [Table - 3] causes of non-formation of A.C. are detailed [Table - 4]. Commonest in the group of P.K. only were wound leaks (61 cases) either primary leak (38 cases) or following suture cut through (23 cases) due to a variety of reasons like raised intraocular tension, suture abcess, tight suture or a combination of these. Swollen lens was the cause in 26 cases while air entrapped in posterior chamber in 6 cases and malignant glaucoma occured in another 3. Among the 12 cases where a combined procedure had been done 9 cases had non formation of A.C. because of excessive filtration or wound leak and in 3 cases lens was seen to be swollen.
Management of each individual case depended upon meticulous search for the cause. Details of management are summarised in [Table - 5]. Conservative treatment of pressure bandage with drugs to lower I.O.P. succeeded only in 7 cases.
Attempt to restore the A.C. depth by suturing with or without lens extraction was made in 58 cases while lens extraction was done in 12 cases. Trabeculectomy had to be done in 15 cases, with or without lens extraction. In 12 cases cyclocryotherapy was done while 2 cases had posterior sclerotomy done. In 64 cases thus A.C. could be formed successfully with improvement in graft clarity, while in 21 cases graft worsened due to reasons like infection, endothelial decompensation, intraocular hemorrhage or endophthalmitis.
| Discussion|| |
Success of corneal grafts is dependent upon both mechanical and biological factors. Among the mechanical factors, restoration of anterior chamber depth following grafting is of prime importance. Several authors from India , and other countries , have reported a varying incidence (23% to 36.6%) of non formation of A.C. depth following penetrating keratoplasty. However, the problem has not been probed for possible causes and the results of their management.
It is seen from our observations described here that most of the cases of non formation of A.C. occur mainly in therapeutic grafts (77.7%) are in grafts larger than 9 mm in size (49 %). This usually occurs in the first week (83.3%) of operation. Such a complication is relatively less often seen when a combined procedure with antiglaucoma procedure was done (4.5%) as compared to P.K. alone (15.7%).
It is an implied conclusion that whenever there is pre-operative associated rise in I.O.P. or there is an expected risk of rise of I.O.P. following keratoplasty, a combined procedure should be preferred particularly in large grafts and cases of Fuch's dystrophy.
Among the causes of non formation of A.C. wound leak (63.4%) and swollen lens (27.1%) are the two most important factors besides trapped air in the posterior chamber (6.3%) and malignant glaucoma (3.2%). In all cases, therefore, a thorough search for wound leak and slit lamp examination to see the state of lens should be made. Detection of even minimal leaks can be made by using schirmer's strips applied at suture site after clearing all the mucous and extra tear fluid from the cornea and conjunctival sac. The area of greater soakage is noted, re-checked and treated for leaks. In as many as 23.9% of cases sutures had partially or totally cut through resulting in wound leak. The causes of suture cutting through were tight suturing, suture abcess, tissue necrosis and raised I.O.P. It will reduce the incidence of non formation of A.C. if suturing is made more perfect and under magnification, suture abcesses are scrapped early and LO.P is kept low particularly during the early post operative period.
In our experience it is easier and more useful to save the graft if the cause is identified earlier and the restoration of non formed A.C. is ensured expeditiously.
Suturing of wound leaks succeeded in 44 cases while in other cases lens extraction, trabeculectomy or cyclocryotherapy had to be done depending upon the incriminating cause(s). Despite the restoration of A.C. depth, graft clarity worsoned in 23 cases. Causes of increased haziness of graft were decompensation of endothelium, occurrence of secondary infection, uveitis, intraocular hemorrhage, rise of I.O.P. and endophthalmitis.
It is of importance, therefore, that appropriate procedure for the restoration of anterior chamber depth should be undertaken at the earliest. Regrafts with or without vitrectomy may be considered in cases of repeated failures at the restoration of anterior chamber.
| References|| |
Malik, S.R.K., and Singh, Gurbax, Proced. Of All India Ophthal. Soc., p. 231, 1969.
Moore, R., and Arentson, J.J., Am. J. Ophthal., 72, 205, 1971.
Binder, P.S., Abel, R., Polack, F.M., and Kaufman, H.E., Am. J. Ophthal., 81,
Dhanda, R.P., and Kalevar, V.K., Am. J. Ophthal., 55,
Arentsen, J.J., Morgan, B., and Green, W.E., Am. J. Ophthal., 81,
Marlin, W.R.J., and Smith, E.L., Am. J, Ophihal., 50. 1199, 1963.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]