Year : 1979 | Volume
: 27 | Issue : 4 | Page : 129--130
Therapeutic penetrating versus lamellar keratoplasty
Gurbax Singh Bhinder, Shashi Prabha Garg, Mohinder Kumar Sanghi
M.A.M. College & Associated Hospital, New Delhi, India
Gurbax Singh Bhinder
M.A.M. College & Associated Hospital, New Delhi
|How to cite this article:|
Bhinder GS, Garg SP, Sanghi MK. Therapeutic penetrating versus lamellar keratoplasty.Indian J Ophthalmol 1979;27:129-130
|How to cite this URL:|
Bhinder GS, Garg SP, Sanghi MK. Therapeutic penetrating versus lamellar keratoplasty. Indian J Ophthalmol [serial online] 1979 [cited 2021 Jan 25 ];27:129-130
Available from: https://www.ijo.in/text.asp?1979/27/4/129/32600
Treatment of herpetic corneal ulcers is still a problem due to lack of an effective anti-viral agent. Many cases have proved to be resistant to the drugs. Then the drugs have no therapeutic effect on stromal disease.
The aim of present communication is to compare the results of lamellar with penetrating keratoplasty in Herpetic cases.
Materials and Methods
Seventy five eyes were operated in this particular group at the corneal service unit of Maulana Azad medical college and J. P. hospital between 1964 to 1977. The age group of the patients ranged between 2 years to 60 years. Therapeutic keratoplasty was necessitated in these cases under following conditions:
No response to medical therapy -16 cases
Stromal keratitis -35 cases
Descematocele - 7 cases
Recurrence in lamellar graft -10 cases
Perforation - 7 cases
Pre-operative regime and anaesthesia:
Six cases were operated under general anaesthesia while rest under local anaesthesia.
Casteroviejo's corneal trephine was used to cut the graft varying from 6.5 mm-10 mm in diameter (lamellar 7-10 mm, penetrating 6.5 mm-8 mm).
The idea was to remove the diseased tissue which was delineated by the quantitative anaesthesiometry using Luneau and Coffignon anaesthesiometer. In cases of descematoceles, a trephine grove of 0.5 mm was made. In one case the dissection could be made upto the descemet's membrane. However, in other cases complete removal of tissue upto descemet's membrane was not achieved.
Homografts were used in all the cases using the operating microscope. Suturing was carried out by using 8 zero silk on eyeless needles in group A. In subsequent cases perlon 8-0 was used. In penetrating grafts, air was introduced into the anterior chamber via the corneal wound at the end of operation. A subcon-junc.ival injection of 0.25 ml. of framycetin sulphate solution was given followed by instillation of atropine and framycetin eye ointment.
The dressings were carried out daily for 21 days by using atropine 1% and soframycin eye oint. Corticosteroids were instilled locally after 1st post-operative week. In lamellar keratoplasty, patient was mobilised on 2nd day while in penetrating keratoplasty, on 3rd post-operative day. At any evidence of graft reaction, corticosteroids were started by systemic route in the dosage of 20-40 mg prednisolone daily. Sutures were removed between 3rd and 4th post-operative week.
This study is divided into two sub-groups:
Group A (earlier series): A total of 37 cases were operated in this group. In 19 cases lamellar keratoplasty was performed where by removal of opaque tissues, the infected tissue was sought to be removed. In the remaining 18 cases, penetrating grafts were given.
Group B (later series) (38 cases): The criterion of obtaining disease free recepient bed through ensuring a clear bed was found to be deceptive. Hence, in the subsequent cases electing penetrating grafts given (24 cases) in all. types of stromal keratitis cases. In 14 cases where the diagnosis of epithelial keratitis was made, an elective lamellar keratoplasty was carried out.
(a) Lamellar keratoplasty: It was carried out in 19 cases. - The study comprised of 2 cases of epithelial keratitis, 13 cases of stromal keratitis and 4 cases of descematocele. Improvement was seen in 7 cases (36.7%) from 6/24 to 6/9. The rest of the 12 cases got reinfected with herpetic keratitis. These cases were saved by penetrating grafts after repeated attempts with a lamellar grafts failed.
In group B, 14 cases had epithelial keratitis with early stromal involvement. A planned deep lamellar grafts were given.
Ten eyes (71.5%) were controlled with improvement in visual acuity from 6/24-6/12. Four eyes (28.5%) developed recurrence which were controlled by subsequent penetrating grafts.
(b) Penetrating keratoplasty:
Group A: Of the 18 eyes of this group, 9 were those where a previous 2 to 3 lamellar grafts had failed. An improvement ranging from 6/18 to 6/9 was seen in 5 eyes (55.5%). Four corneal grafts turned opaque. In the remaining 9 cases elective penetrating was carried out. Of these 8 eyes improved in visual acuity from
6/36 to 6/9. No improvement was seen in one case as it turned opaque due to recurrence of disease in graft.
Group B: Out of the 24 cases of This group, 17 cases (70.9%) showed improvement in visual acuity ranging from 6/24 to 6/6. No improvement occurred in 7 cases (29.1%) as the graft turned opaque due to graft reaction.
Lamellar keratoplasty has been advocated in cases of active herpetic infections as a choice procedure (Paufique 3 . In the persent series we noticed that lamellar keratoplasty has only a place in cases of first or second attack of superficial epithelial keratitis which do not respond to medical treatment. The results of lamellar keratoplasty in the above type of cases have been very encouraging (71.5%). However, if lamellar keratoplasty is done as a choice procedure (Group A) in all cases we noticed that the failure rate rose to 63.3%. This finding is in agreement with other investigators who have also pointed out that lamellar keratoplasty is not the procedure of choice.(Polack and Kaufman, Langston et al, and others).
In the preseut study, the results of penetrating keratoplasty have been very good (75%). The recurrence rate of the infection is very low. The cases which become opaque are those which developed graft reaction. Our results are as good as of Polack and Kaufman. The present study reveals that the penetrating keratoplasty in cases of failed lamellar grafts gives a lowered success rate (55.5%). Similar are the observations of Polack and Kaufman and Langston et al.
Summary and conclusion
Therapeutic keratoplasty was performed in 75 eyes. Lamellar keratoplasty was performed in 33 cases and penetrating keratoplasty in 42 cases. In superficial herpes, lamellar keratoplasty gives good results if the lesion has developed after 1st and 2nd epithelial attack of herpes.
In stromal herpes, descematocele and perforated ulcers, procedure of choice is elective penetrative keratoplasty which gives results (75%).
Recurrences following penetrating keratoplasty are less frequent. However, graft reaction are seen more frequently in these cases.
|1||Langston R.A.S., Langston, D.P. and Dohlman, C.H., 1975, Trans. Amer. Acad. Ophthal Otolaryng., 79, 577.|
|2||Polack, F.M. and Kaufmann, H.E., 1972, Amer. J. Ophthal., 73, 908.|
|3||Paufique, L., 1949, Trans. Ophthal. Soc. U.K., 69, 67.|