|Year : 1984 | Volume
| Issue : 5 | Page : 402-404
Corneal regrafting analysis of results
M Srinivasan, Gullapalli N Rao, James V Aquavella
Department of Ophthalmology, University of Rochester Medical Centre, Rochester New York, USA
Gullapalli N Rao
M.D., 919 Westfall Road, Rochester, New York 14618-2699
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Srinivasan M, Rao GN, Aquavella JV. Corneal regrafting analysis of results. Indian J Ophthalmol 1984;32:402-4
Despite the significant advances made in the field of corneal transplantation, corneal graft failure continues to be a problem requiring, in some instances, regrafting for visual rehabilitation of these patients. Although the overall success rate of corneal transplantation at this time is in the range of 75 to 80 percent, no information is available on the results of regrafting. In an attempt to address this question, we have conducted a reatrospective analysis of all cases where regrafting was performed during the past 4 years.
| Materials and methods|| |
69 eyes of 64 patients who underwent corneal transplantation for a failed corneal graft have been included in this study. Failed graft, according to our definition, is an opaque corneal graft requiring a regrafting for visual rehabilitation. The patients ranged in age from 39 years to 76 years with a mean age of 58.3 years. The follow-up period of these patients ranged from 21 to 86 months.
In all these cases, the donor material was preserved in McKarey-Kaufman medium for a period of less than 72 hours.
The surgical procedure was a standard surgical procedure for penetrating keratoplasty. We have employed 8 interrupted and 1 running 10-0 nylon suture in 48 eyes and in the remainder of the cases, 16 to 20 interrupted 100 nylon sutures were used. Anterior vitrectomy was performed in about 42 of these cases. Cataract extraction at the time of the second corneal grafting was performed in only 5 cases. The surgery in all these cases was performed by two surgeons (JVA and GNR). Postoperative management included the usage of topical Prednisolone acetate 1% eye drops every hour for the first two days, followed by gradual tapering depending on the clinical response. In addition, these patients were started on systemic Prednisolone at a dosage of 40mg orally and this was also tapered over a period of about three to four weeks depending on the clinical picture. In addition, the patients were given Garamycin eye drops two to four times a day. Some of these patients were given cycloplegics in cases where there was a marked degree of inflammatory reaction. Any evidence of elevated intraocular pressure on pneumotonometry was treated with topical Timalol 0.5% eye drops twice a day along with acetazolamide at a dosage of 500mg B.D.
Four of the patients required cyclocryotherapy for persistent elevations in intraocular pressure following the regrafting. Eight of the patients required synechiotomy for peripheral anterior synechia formation. In two of the cases, pars plana vitrectomy was performed combined with anterior synechiotomy. The patients were followed at weekly intervals during the first month, followed by bi-weekly intervals for two months following which every month for a period of a year with the frequency of visits depending on the clinical status of the eye.
| Observations|| |
The visual results of these patients are summarized in [Table - 1]. As is obvious from the table, only 14 of these eyes (20%) had a final visual acuity of better than 6/12. The preoperative visual acuity was worse than 6/36 in all these eyes. Of the remainder, 24 eyes achieved a final visual acuity of better than 6/ 24. All these eyes had a preoperative visual acuity of worse than 6/60. Two of these eyes had only light perception to hand motion vision with the optic nerve showing irreversible glaucomatous damage. Three eyes presented evidence of macular degeneration and in four eyes where the visual acuity-could not be improved beyond 6/60, persistent cystoid macular edema was noted. In 3 of those eyes, the original pathology was pseudophakic bullous keratopathy secondary to an iris supported intraocular lens implant.
We then attempted to correlate with original corneal pathology for which corneal transplantation was done initially. No significant correlation could be made except in 3 cases of alkali burns, 2 cases of active bacterial corneal ulceration and I case of mycotic keratitis where the regrafting did not produce a significant visual improvement.
The complications in this series included the presence of peripheral anterior synechia in about 12 eyes. 7 of these developed episodes of allograft rejection phenomenon. Four eyes developed scarring from persistent epithelial defect leading to stromal problems. Elevations in intraocular pressure was noted in 18 of the aphakic eyes. Although this problem could be controlled, there was some degree of damage to the optic nerve from the elevated intraocular pressures curtailing the visual acuity in these patients. Deep stromal vascularization occurred in 12 eyes, again contributing to some of the graft problems. This was more common in cases of ocular inflammatory disease and could lead to allograft rejection in eyes.
There was no correlation between age of the donor, or age of the recipient and the ultimate results.
| Discussion|| |
The application of modern methods of microsurgery and advances in eye banking, make corneal regrafting a viable option for the treatment of corneal graft failure. Our study highlights some of the problems and complications that may occur in these eyes.
The complications noted are those already recognized to be associated with corneal transplantation. Early recognition and immediate attention to these problems may minimize the risk of ultimate graft failure.
Synechiotomy and reformation of anterior chamber in cases of peripheral anterior synechia reduces the risk of recurrent episodes of inflammation and allograft rejection. Prompt treatment of allograft rejection very often leads to successful outcome. Refractory secondary glaucoma is a serious problem following penetrating keratoplasty particularly in aphakic patients. Using disparate size grafts, postoperative monitoring of intraocular pressure, and use of appropriate measures to control glaucoma, will help to avert the many disasterous consequences of this problem.
Deep vascularization can be fatal to a corneal graft. Use of high doses of topical and systemic steroids can control this problem. In those cases where ocular surface problems are likely, attention should be paid to select donor cornea with intact epithelium and the surface of the graft has to be protected in the postoperative period.
The results of regrafting can be encouraging if these patients have adequate follow-up and prompt treatment of complications. Any laxity in the postoperative care will lead to escalation in the risk for graft failure.
| References|| |
Polack F.M., 1977. Corneal Transptantation, New York. Grune and Stratton. p. 188.
Olson R.J., Kaufman H.E. 1977. Invest Ophthalmol, 16:1085-1092.
[Table - 1], [Table - 2]