opth 22959 outcome of penetrating keratoplasty in corneal ulcer a sing 090211
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8/3/2019 OPTH 22959 Outcome of Penetrating Keratoplasty in Corneal Ulcer a Sing 090211
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© 2011 Sdpou t al, publs ad lcs Dov Mdcal Pss Ltd. Ts s a Op Accss atclwc pmts ustctd ocommcal us, povdd t oal wok s poply ctd.
Clcal Optalmoloy 2011:5 1265–1268
Clinical Ophthalmology Dovepress
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http://dx.doi.org/10.2147/OPTH.S22959
Outcom of ptat katoplasty coalulc: a sl-ct xpc
Moammad rza Sdpou
raa Sokab
Abdolla Sas
hassa Da
Dpatmt of Optalmoloy,Tabz Uvsty of Mdcal Sccs,Tabz, ia
Cospodc: raa Sokabnkooka hosptal,Abbas Av, Tabz, iaTl/Fax +98 411 337 5457emal [email protected]
Background: Corneal ulcers oten lead to scarring and astigmatism, and signicant loss o
vision is a common consequence.
Objective: To determine the rate o grat rejection, one o the most serious concerns with
this procedure, and to evaluate the recovery o visual unction in those patients or whom the
operation was successul.Methods: We describe a retrospective study o 33 corneal ulcer patients undergoing penetrating
keratoplasty (PK) at the Tabriz Nikookari Eye Hospital.
Results: Mean age o the patients was 44 ± 14 years. Most common risk actors or active
keratitis were trauma, dry eye, and malnutrition. Culture-positive results included bacterial
keratitis (n = 15) and ungal keratitis (n = 5). Peroration was a signicant risk actor or
therapeutic ailure ( P , 0.05). Age or gender had no statistically signicant eects on the PK
outcome ( P . 0.05). Postoperative visual acuity had a signicant association with preoperative
visual acuity ( P , 0.01). Grat rejection rate (27.2%) was similar to that reported in the
literature.
Conclusion:Although lamellar keratoplasty has recently been established, there are practical
reasons or continuing the use o PK in centers such as ours, with due attention to the requirement
or topical immunosuppression to diminish the rate o grat rejection and antimicrobial treatment
to prevent postoperative inection.
Keywords: keratitis, ulcerative, grat rejection, peroration
IntroductionCorneal ulcers oten lead to scarring and astigmatism, and signicant loss o vision
is a common consequence. In severe cases, peroration, scleral involvement, and
endophthalmitis may occur. Corneal ulcer together with ocular trauma are the major
causes o blindness in developing countries.1 Dierent types o ulcers result rom
dierent pathological processes and require dierent management approaches.2
Keratitis is usually caused by bacteria and ungi.3,4 Recently, ungal causation associated
with sot contact lens use has become an increasing cause o concern.5 Chemical burns
by strong acids or alkalis are relatively prevalent among young patients.6
I corneal peroration seems likely, urgent management is required, since corneal
peroration has high morbidity,7 and keratoplasty is a common procedure.2 Amniotic
membrane transplantation has proved successul as an adjunctive method or corneal
re-epithelization,3,8 but has not replaced keratoplasty, partly because o availability o
donor tissue. Penetrating keratoplasty (PK) is a well established technique; however, long-
recognized complications such as postoperative inection, corneal and macular edema,
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Clinical Ophthalmology
2 September 2011
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Ptat katoplasty coal ulc
Twenty-seven patients (81.8%) achieved therapeutic
success. Therapeutic ailure occurred in 4 eyes with limbal
extension and two eyes with perorated ulcer. Three eyes
had ungal keratitis. Inection recurrence time varied rom
4 days to 1 year, most recurrences (n = 4) appearing within
6 weeks o surgery. Possible risk actors or ailure were
analyzed. Peroration was a signicant risk actor ( P , 0.05),
but limbal extension was not shown to be a denite predictor
or therapeutic ailure ( P . 0.05) in our cases.
General complications included endothelial rejection
(n = 9), glaucoma (n = 7), and phthisis bulbi (n = 2).
Glaucoma was controlled by medication. Rejection was
reversed in six eyes, whereas three cases o rejection resulted
in late grat ailure. Grat rejection presented as photophobia,
eye redness, visual blurring, and pain, in descending order
o requency. Age or gender had no statistically signicant
eects on PK outcome ( P = 0.447 and 0.715, respectively).
Five patients underwent simultaneous cataract surgery.
Postoperative visual acuity had a signicant association with
preoperative visual acuity ( P , 0.01).
DiscussionOur corneal ulcer patients covered a wide age and gender
range. Thereore, our nding that age and gender had no
signicant infuence on our outcome measures could be
generally valid. For those patients in whom the grat was not
rejected, visual unction markedly improved, supporting the
view that PK is a valuable procedure or patients with corneal
ulcer in spite o the associated risks. The grat rejection rate
(27.2% o the total cohort) is broadly consistent with values
in the literature.20–22
The immune reaction associated with microbial kera-
titis and corneal transplant rejection has been studied in
detail and was reviewed by Dana et al.23 Essentially, local
Langerhans cells and other antigen-presenting cells are
activated, pro-infammatory cytokines such as interleukin-1
and tumor necrosis actor-α are upregulated, and a range
o immune unctions ensues, resulting in the recruitment
o neutrophils and T helper type 1 lymphocytes and matrix
metalloproteinase activation. The consequences can entail
considerable corneal injury. Systemic immunosuppressants
are not recommended or PK patients, but topical steroids
supplemented with agents such as cyclosporine have been
shown to be eective in reducing allograt rejection rates and
should be considered.24–26
Recent advances in lamellar keratoplasty accompanied by
antimicrobial treatment have also improved the success rate in
terms o visual unction and inection.27 It is less invasive than
PK and vision is recovered more rapidly ater the operation,
and since long-term corneal sutures are not required, the
problems associated with such sutures are eliminated. On
the other hand, there is an absolute requirement or specially
prepared donor tissue and surgeons with specic training or
experience with the technique. In centers such as ours, these
are currently not options. Thereore, with due attention to the
need or topical immunosuppression and treatment to combat
postoperative inection, there is a strong case or continuing
the use o PK or corneal ulcer patients.
In summary, although the mainstay o initial management
o severe inective keratitis remains aggressive antimicrobial
therapy to limit spread to the sclera and AC, the role o
timely surgical intervention in the orm o therapeutic
keratoplasty should be considered in view o the relatively
successul outcomes in our series o patients with severe,
end-stage disease. The timing o surgery is critical or good
therapeutic outcomes, which we believe may be enhanced
by earlier rather than later intervention, because scleral or
intraocular extension o inection is likely to result in poorer
outcomes.
DisclosureThe authors declare no conficts o interest in this work.
References1. Whitcher JP, Srinivasan M, Upadhyay MP. Corneal blindness: a global
perspective. Bull World Health Organ. 2001;79:214–221.
2. Tuli SS, Schultz GS, Downer DM. Science and strategy or preventing
and managing corneal ulceration. Ocul Surf . 2007;5:23–39.
Figure 2 Outcom of t ptat katoplasty a patt wt coal ulc.
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