Indian Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 1984  |  Volume : 32  |  Issue : 5  |  Page : 394--398

Penetrating keratoplasty in primary fuch's dystrophy


M Mohan, A Panda, S Chawdhary 
 Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi, India

Correspondence Address:
M Mohan
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi
India




How to cite this article:
Mohan M, Panda A, Chawdhary S. Penetrating keratoplasty in primary fuch's dystrophy.Indian J Ophthalmol 1984;32:394-398


How to cite this URL:
Mohan M, Panda A, Chawdhary S. Penetrating keratoplasty in primary fuch's dystrophy. Indian J Ophthalmol [serial online] 1984 [cited 2021 Sep 18 ];32:394-398
Available from: https://www.ijo.in/text.asp?1984/32/5/394/27520


Full Text

Primary Fuch's dystrophy of the cornea has been a very frustrating condition to treat till comparatively recent past since the keratoplasty failure rate was close to 100%[1]. It was considered contraindicated by some sur­geons[2], till Stocker's first report of success[3] established the pre-requisites for attaining good results. An early keratoplasty was favoured by many workers[3],[4], while, in view of uncertainties of keratoplasty, some preferred to wait till vision deteriorated to less than 6/36[5]. The reported success in various series varies from 50% to 95%, the results being better in early cases as compared to those with advanced dystrophic changes[2],[6].

Senile cataracts are present in a significant number (50%) in cases of Primary Fuch's dys­trophy[7]. The timing of keratoplasty and cataract surgery needs careful planning.[4] High incidence of open angle glaucoma (15%) has been described in advanced cases of Primary Fuch's dystrophy.[8] Pre-operative control of intraocular pressure is vital for the success of penetrating keratoplasty.[9]

Experiences of penetrating keratoplasty, in Primary Fuch's dystrophy, with special reference to the management of cataract and glaucoma is presented.

 MATERIALS AND METHODS



The present study reports the results of penetrating keratoplasty performed on 28 eyes of 26 patients of Primary Fuch's dys­trophy, followed for a period of 6 months to 5 years. The cases were selected from the Eye Bank clinic of Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi. The mean age was 50.6 years. Only cases with definite stromal and epithelial oedema were operated upon [Figure 1]. Early cases with changes limited to the endothelium were not taken up for sur­gery for a variety of reasons. The graft size varied from 7 to 9.0mm. Trabeculectomy was performed in 4 eyes for high intraocular pre­ssure and in another 6 eyes in anticipation of large grafts, before undertaking keratoplasty.

4 eyes underwent lens extraction along with penetrating keratoplasty and 4 were operated for cataract during the follow up.

 OBSERVATIONS



The cases were divided into 3 groups depending upon the size of corneal graft [Table 1]. The best results after surgery were achieved in group I [Table 2] [Figure 2][Figure 3]. Con­sidered as a whole, 50% eyes gained vision bet­ter than 6/12 and 25% eyes varying from 6/18 to 6/36. Group III achieved vision better than 6/12 in 14% of eyes.

[Table 3] shows the results of lens extraction in Primary Fuch's dystrophy [Figure 4]. In the 4 eyes where cataract surgery and penetrating keratoplasty were done as a combined pro­cedure graft remained clear in one eye [Figure 5] partially clear in 2 eyes [Figure 6] and became totally opaque in one eye. Out of the 4 eyes where cataract surgery was done at least 6 months after keratoplasty graft became opa­que in one eye and remained partially clear in 3 eyes.

Trabeculectomy was done in 5 eyes before keratoplasty and in 5 eyes along with keratoplasty. 4 eyes were operated for elevated intraocular pressure and 6 eyes in anticipa­tion of large grafts [Table 4]. Visual improve­ment is highlighted in [Table 5].

Trabeculectomy was done in 4 eyes for post operative glaucoma [Table 4]. Visual results of these cases are shown in [Table 6].

 DISCUSSION



The successful treatment of Primary Fuch's dystrophy of cornea by penetrating keratoplasty is one of the triumphs of modern ophthalmology.[4],[6],[7],[8] The disease previously considered incurable,[1] now in its early stages represents one of the good indications for optical keratoplasty.[6],[7]

The best results after keratoplasty are achieved in early cases. Some authors have reported good results in moderately advanced cases of Primary Fuch's dystrophy, not much inferior to those obtained in early cases.[7] Thus while the incidence of successful keratoplasty is slightly higher in cases operated early, failure in these very cases are much more serious in terms of visual loss. In this series the results in group I and group II are nearly iden­tical. We do not recommend surgery till the vision has dropped to 6/36, since the risk of operation at early stage outweighs the advan­tages. nevertheless the results of surgery at an advanced stage are also poor and surgery should not be unduly delayed. The optimum time for surgery, in our opinion, is when the disease is advanced to such an extent that graft size required would not be more than 9.00 mm.

The management of cataract in cases of Primary Fuch's dystrophy is controvertial. Most surgeons favour keratoplasty first and lens extraction at a later stage[7]. Others advise a combined procedure[5] and even a triple pro­cedure along with intraocular lens implan­tation.[10] In this series of the 4 eyes where lens extraction and keratoplasty were done at the same surgery, graft remained clear in 1 eye, partially clear in 2 eyes while in one eye, where vitreous face was broken, graft became opa­que. Out of the 4 eyes in which lens extraction was done at a second stage, grafts remained clear in none, partially clear in 3 eyes and opacified in remaining I eye. The graft opaci­fication in this eye could be traced to intra operative complication of ruptured lens cap­sule. Though the number of cases in the two groups is small the results tend to favour lens extraction being done along with penetrating keratoplasty. This also speeds up the visual rehabilitation of the patient.

The incidence of open angle glaucoma was 14% which is in agreement with previous reports.[8] In the 5 eyes where trabeculectomy was done before keratoplasty and 5 eyes where trabeculectomy was combined with keratoplasty no instance of post operative glaucoma was seen. The visual results were marginally better in the group where trabe­culectomy was done prior to keratoplasty, but a larger series is required to confirm this. 50% of the eyes where trabeculectomy was done before or during keratoplasty, gained vision 6/12 or better. Out of the 18 eyes where no antiglaucoma surgery was done, 4 eyes developed secondary glaucoma after kerato­plasty and required trabeculectomy. None of these eyes achieved vision 6/12 or better, 3 eyes attained vision varying from 6/18 to 6/36 and one eye less than 6/60. This shows that post operative glaucoma is very damaging to the graft We recommend trabeculectomy before keratoplasty in all cases with elevated intraocular pressure and those requiring grafts more than 9 mm, where the risk of secondary glaucoma is substantial.

 SUMMARY



Results of penetrating keratoplasty per­formed in 28 eyes of 26 patients of Primary Fuch's dystrophy of cornea with a follow up of 6 months-5 years are presented. Successful results were achieved in 75%, eyes. Pre­operative control of glaucoma is very impor­tant for success. The incidence of primary open angle glaucoma was 14%. Penetrating keratoplasty at a moderately advanced stage of the disease is recommended. Lens extrac­tion along with penetrating keratoplasty should be preferred.

References

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3Stocker F.W., 1952. Amer. J. Ophthalmol., 35: 349
4Paton RT., Schwartz G.; 1959. Arch. Ophthalmol., 61: 366
5Hughes W.F., 1900. Amer. J. Ophthalmol., 50: 1100
6Olson R1, Walterman SR., Matingly T.P. and Kauf­man H.E., 1979. Amer. J. Ophthalmol., 88: 1000
7Fine M., 1964. Amer. J. Ophthalmol., 57: 371
8Becker G., Schaffer R, 1965. Diagnosis and Therapy of Glaucomas, St. Louis CV Mosby Co., p 74: 108
9Mohan M., Mukherjee G., Chawla KS., 1980. Proc. of 39th Ann Conf. of AIOS, Manipal, 182.
10Bruner W.E., Stark W.J., and Maumenee AE., 1981. Ophthal. Surgery, 12: 657