Year : 1984 | Volume
: 32 | Issue : 5 | Page : 390--393
Keratoplasty in children
Guru Gobind Singh International Eye Centre, New Delhi, India
Guru Gobind Singh International Eye Centre. New Delhi
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Singh G. Keratoplasty in children.Indian J Ophthalmol 1984;32:390-393
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Singh G. Keratoplasty in children. Indian J Ophthalmol [serial online] 1984 [cited 2022 Jul 5 ];32:390-393
Available from: https://www.ijo.in/text.asp?1984/32/5/390/27519
Corneal opacification in children not only produces blindness but also deprives them of the advantages of binocularity. Also, visual deprivation produces faulty mental development. Keratoplasty, thus, carries an utmost significance in the paediatric ages; however corneal grafting in children has been performed with great reservation because of the poor co-operation in the postoperative period.
The few communications available on this subject,,, mainly comprise of single case reports, while only 3 big series,, on this subject are available. The present report is based upon experience with 185 keratoplasties done in children.
METHODS AND MATERIAL
A total number of 185 cases, in the age group of 18 days to 14 years, underwent keratoplasty under general anaesthesia. The keratopla sty comprised of41 lamellar and 144 penetrating grafts, of these 100 patients were male and 85 female. A total number of 56 children were below the age of 5 years and 129 were in the age group of +5-14 years. Right eye was operated in 94 cases, left in 90 and 1 patient was operated in both eyes. [Table 1].
The size of the grafts varied from '6 to 10 mm. The grafts were retained with interrupted or continuous, 8-0 virgin silk or perlon sutures. Anterior. chamber was reformed with sterile air in penetrating Keratoplasty.
The postoperative follow up was carried out under short acting anaesthesia every third or fourth day during the hospital stay, of younger, non cooperative patients. The patients were looked for any complication like infection, anterior synechiae and hyphaema. Local application of Framycetin Eyedrops & atropine ointment 1% was started from the first post operative day. Parenteral and local steroids were started in the second week. The sutures were removed after 21 days. The patients have been followed up for a period of 1 to 20 years.
185 cases of grafting in children have been divided into two groups.
Group I Comprised of 56 cases between 18 days to 5 years of age. This group was further subdivided into two.
Group II Comprised of 129 cases between 5 to 14 years of age. It was further subdivided into two groups.
Graft transparency: The relationship of the graft clarity with the host pathology, the age of the recepient, the type of keratoplasty performed, and the size of the graft is given in [Table 2][Table 3][Table 4][Table 5].
a) Type of corneal disease: There was a statistically significant difference between various Corneal pathologies and the graft transparency (P 0.05). Best results were seen in keratoconus cases [Table 2]. In caustic burns the results were the worst [Table 3].
b) Size of graft: There is stastically significant difference in the results in penetrating keratoplasties of various sized grafts (P 0.05). The results are best with 7 mm graft. There is a steep fall of results if the size of graft is more than 7.5 mm [Table 5].
c) Age Group of recepient: There were 66% transparent grafts in group I & 74% in group II [Table 5]. This difference is due to the relatively more number of cases of large grafts (7.5mm) and due to undertaking of cases of keratomalacia in the Group I series [Table 4] in which failure rate is high. d) Relationship to preoperative iris adherence: Corneal transplants in Group I & Group II cases were 64% successful as compared to 83% success in less adherences. e) Type of Keratoplasty: In optical grafting the results were better (80.6%) as compared to therapeutic grafting.
f) Complications: The complications seen in the cases are recorded in [Table 3]. Epithelial Ulcers were seen in 15% of the cases. There was an increased incidence of anteriorsynechia which was seen in 22 cases (50%) of age below 5 years & 25% of cases between 5-14 years Graft sickness was seen in 15% of cases of Group I and 5% cases of Group 11 cases. g) Visual acuity: In the age group below 5 years it was not possible to test the vision, till they reached the age of 6-7 years. Follow up showed that visual acuity improvement in all the 8 cases of Lamellar grafting to 6/12 & 6/18. The visual acuity in P.K-in this group improved to 6/6 in 14 cases and 6/9-12 cases & 6/12 in 4 cases. The visual improvement in Group II cases was seen in 74% of the P.K and 69.7% of the L.K Group as compared to 65% of P.K and 100% of L.K Group in Group I case.
It has been the general opinion in the past not to do any keratoplasty in children below 14 years of age.,, In our previous study, it was noticed that the amblyopia and eccentric fixation developed in those cases when onset of opacity was before 5 years age and were operated at a much later date. This study prompted us to perform keratoplasty as early as possible after a corneal pathology in children. 185 cases of corneal grafting have been performed in children between 18 days to 14 years of age.
Lamellar keratoplasty achieved a success of 100% in Group I as compared to 69.7% in Group II. This difference in results is attributed to least incidence of recurrence of herpes in children in Group I after a deep lamellar graft was given, a finding of statistical significance (P 0.05).
Penetrating keratoplasty achieved 65% success in Group I and 74% success in Group II. The results have a statistically significant value (P 0.05). The factors which attributed to lowered success in Group I is chiefly the larger size of the graft (7.5mm) which has to be given in therapeutic corneal grafting below 5 years of age. The other' insignificant factors could be (1) Non reformation of anterior chamber on operation. (2) Larger incidence of anterior synechia and (3) noncooperation on part of patient.
The successful results of keratoplasty in optical grafts were 80.6% and in therapeutic grafting were 69.6%. This bears a stastically significant difference between the two group (P 0.05). The factor which lead to the difference are larger sized grafts and increased incidence of anterior synechiae.
The diameter of corneal graft bears a direct relationship to the transparency of grafts. The results were best with 7.00 mm graft. The results tend to be inferior if the graft is more than 7.5 mm size [Table 5]. The larger sized graft lead to increased complications due to anatomically shallow anterior chamber, buldge of iris lens diaphragm on table, difficulty in reformation of anterior chamber and greater incidence of anterior synechia & graft reaction.
Lamellar keratoplasty is safe and may be contemplated in all cases if the corneal bed can be made transparent after dissection of the corneal finding in agreement with Waring & Laibson. This does not agree with Picetti and Fine who advocate the penetrating keratoplasty in every case in children below 6 years due to fear of amblyopia as a result of interface opacity.
The overall results of keratoplasty in this series of Group la and Ila are good (83%) and can be compared well to results seen by Picetti & Fine-80%, : Waring & Laibson-87%. The better result in this series than that of Petromya and Sokolik as 48-1% is due to absence of total corneal graft in the present series.
SUMMARY & CONCLUSIONS
The author has presented a data of 185 cases of kertoplasty in children between 18 days to 14 years.
1. 56 cases were between 18 days to 5 years & 129 cases are between 5-14 years.
2. The results of optical grafts were much better than the therapeautic grafts, the difference was due to relatively larger sized grafts in the latter series.
3. The author has noted that Graft transparency is related to size of graft used, type of corneal disease, age and type of keratoplasty performed.
4. The results are best with 7 mm penetrating grafts.
5. 66% of the corneal grafts were-transparent below 5 years and 74% between 5 to 14 years.
6. The rate of complication was not too much in children if the size of graft was below 7.5mm however if the size was more, increased incidence of complication.
7. The author has recommended lamaller or penetrating Keratoplasty in children keeping in view specially the smaller size of the grafts., and reformation of anterior chamber on the table.
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