Impact of pandemic COVID-19 lockdown on penetrating keratoplasty patients

Purpose: To study the impact of the COVID?19 lockdown on the regular follow?up of keratoplasty patients. Methods: This retrospective interventional case series included 30 patients who had immunological corneal endothelial rejection out of 190 patients who came for post?PKP follow?up between September 15, 2019, and September 30, 2020. The demographics, primary diagnosis, surgical technique, time of presentation, recovery of graft, associated ocular problems, and visual acuity at 1 month were analyzed. Forward stepwise (likelihood ratio) binary logistic regression was used to find significant variables. Results: The study population had 19 males (63.33%) and 11 females (36.67%). The mean age of the study group was 42.83 ± 18.89 (8–80) years. Of 30 patients, 19 (63.3%) presented before and 11 (36.7%) after the COVID?19 lockdown. Overall, 23 (77%) showed a reversal of graft rejection. Logistic regression showed that preoperative indications, large?sized grafts, and deep corneal vascularization were significant risk factors for non?resolution of graft rejection. It was noted that patients who presented to the hospital late had poor recovery (P = 0.002). The delay in the presentation was a significant risk factor for non?resolution of graft rejection (P < 0.01). Z?test for proportions revealed that the difference in the non?resolution of rejection on immediate or delayed treatment in patients presenting during lockdown (P = 0.002) was significant. Conclusion: This article is to highlight the impact of the COVID?19 lockdown on graft rejection recovery of PKP patients due to delays in follow?up. Early treatment helps in the recovery of graft transparency and the reversal of immunological graft rejection. Also, primary diagnosis, deep vascularization, and large?sized grafts were significant risk factors for non?resolution of graft rejection.

Innovative intra-corneal ring-supported graft surgery for treatment of keratoconus and cornea regeneration: Surgical technique and case report

Therapeutic options for corneal ectasia are evolving, with emphasis on the intra-stromal corneal ring for delaying or eliminating the need for penetrating keratoplasty. A 33-year-old man with grade 4 keratoconus and rising intolerance of the hard contact lens underwent a combination of a new innovative ring and graft with suture in the left eye. Excellent structural support and stability of the cornea were observed immediately post-operatively and 12 months after surgery. It appears as a feasible and safe therapy option for keratoconus eyes with reference to the instability and asymmetry of the cornea. Hence, as a safe and effective technique, it can be performed easily.

Using corneal graft from keratoconic donor for lamellar and penetrating keratoplasties

We report the use of two corneal grafts derived from a donor, with a history of early stage keratoconus, for lamellar and penetrating keratoplasty. The first graft was used to perform Descemet stripping automated endothelial keratoplasty (DSAEK) in a patient with endothelial dysfunction and advanced pseudoexfoliative glaucoma. The second graft was used for an emergency penetrating keratoplasty in a patient with corneal perforation secondary to uncontrolled herpes keratitis. In the first case, 1 year postoperatively, the graft was clear and attached with no signs of rejection or failure. In the second case, the perforation did not relapse after keratoplasty and the globe retained its structural integrity during the 1-year follow-up.

Graft epithelial mapping following penetrating keratoplasty using anterior segment optical coherence tomography / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To evaluate the changes in corneal epithelial thickness in corneal grafts following penetrating keratoplasty(PK)using anterior segment optical coherence tomography(AS-OCT), and to determine the role of epithelial thickness mapping in the early detection of graft rejection.<p>METHODS: This prospective comparative observational study included 20 patients(20 eyes)who underwent PK as study group and 16 patients(16 eyes)as control group. Corneal epithelial thickness mapping using AS-OCT was performed at 2wk, 1 and 3mo postoperatively. The parameters of epithelial thickness and distribution at the 3mo were compared to 16 patients(16 eyes)with allograft rejection following PK.<p>RESULTS: There was significant decline in the superior, inferior, maximum, and minimum epithelial thickness values of the study group at 1mo compared to 2wk(<i>P</i>=0.0004, 0.0001, 0.0001, 0.04 respectively)with no significant differences at 3mo compared to 1mo(<i>P</i>=0.4, 0.1, 0.8)respectively. Percentage of reduction in epithelial thickness was significantly higher than that of stromal thickness at 1mo compared to 2wk(<i>P</i>=0.04). The epithelial thickness maps showed a similar pattern of epithelial thickness distribution in the study group and in the rejection group showing considerable corneal edema. However, the allograft rejection group showed irregular pattern of epithelial thickness distribution in patients showing relatively higher central corneal thickness(CCT)as measured by pachymetry map.<p>CONCLUSION: Quantitative assessment of graft epithelial remodeling following PK shows early changes that contribute to significant corneal graft thickness changes. Changes in corneal epithelial thickness and pattern of distribution could be used as an indicator for corneal graft rejection.

Use of Tachosil® as an adjuvant therapeutic option in neurotrophic keratopathy in order to prevent perforation

We present two cases of women who suffered from neurotrophic keratopathy (one of them had undergone penetrating keratoplasty) which had led to corneal thinning. Tachosil® was used as an adjuvant treatment after topical medication by itself failed in both cases. To our knowledge, there are no reported cases of the use of Tachosil® in corneal grafts.

Indicaciones y técnicas de trasplante de córnea en una clínica oftalmológica privada en Colombia / Indications and techniques of corneal transplantation in a private ophthalmologic clinic in Colombia

Introducción: el trasplante de córnea es el injerto mas frecuente en el campo de la medicina; las técnicas para realizarlo han evolucionado permitiendo hacer procedimientos menos invasivos, con menor riesgo de rechazo del injerto y con una recuperación más rápida. La escasez de donantes para realizar trasplantes de córnea, genera una limitación terapéutica muy importante en el campo de la patología corneal. Objetivo: Reportar las Indicaciones y Técnicas empleadas en los Trasplantes de Córnea, en una institución privada con atención terciaria en Oftalmología en Bogotá, Colombia. Diseño del Estudio: Estudio transversal de fuentes secundarias. Método: Se hizo un estudio transversal, con las historias clínicas electrónicas de los pacientes operados con algún tipo de trasplante de córnea, en la Clínica Barraquer de América en el periodo comprendido desde Enero del 2010 a Diciembre del 2018 Resultados: Las cuatro primeras Indicaciones para Trasplantes de córnea fueron: 1) Ectasias Corneales 38.27% 2) Descompensación corneal 20.88% 3) Reposición de Injerto 17.72% 4) Leucomas Cicatriciales 16.22%. Las técnicas empleadas fueron Injerto Penetrante el 54.11% - Injertos Laminares (43.52%) con un 17.25% de Injertos Endoteliales. Conclusión: Existen diferencias en la frecuencia de las Indicaciones para trasplante de córnea según la región del país y también respecto a las publicaciones internacionales. El Queratocono fue la indicación mas frecuente. La Queratoplastia Penetrante la técnica más frecuente como procedimiento primario, pero también como técnica alternativa debido a la falta de oportunidad para realizar el trasplante.

Background: corneal transplant is the most frequent graft in the fi eld of medicine; the techniques to carry it out have evolved allowing to make less invasive procedures, with less risk of rejection of the graft and with a faster recovery. The shortage of donors to perform corneal transplants generates a very important therapeutic limitation in the field of corneal pathology.. Objective: To report the Indications and surgical techniques in Corneal Transplants in a tertiary referral center and private Ophthalmological clinic in Bogotá-ColombiaStudy Design: Cross sectional study using secondary data. Method: A cross sectional study was performed with the electronic clinical records of the patients that had a corneal graft of any kind during the period between January 2010 and December 2018 at the Barraquer Clinic in América. Results: The top four indications for corneal transplantation were: 1) Corneal Ectasias 38.27% - 2) Bullous Keratopathy 20.88% ­ 3) Re-Graft 17.72% and 4) Leucomas 16.22%. Penetrating Keratoplasty was the most common indication (54.11%) followed by Lamellar Techniques 43.52% of which Endothelial keratoplasty was performed in 17.25%. Conclusion: Corneal transplant indications and its frequency, are different between country regions in Colombia and towards international reviews. For us, Keratoconus was the most frequent indication. and Penetrating Keratoplasty, the most frequent technique as a primary procedure, but also as an alternative technique due to the lack of opportunity to perform the transplant.

Resultados visuales y sobrevida de injerto obtenidos en una población pediátrica sometida a queratoplastia / Visual outcomes and graft survival in pediatric patients underwent penetrating keratoplasty

Objetivo: Describir resultados visuales y complicaciones de una serie de casos de pacientes pediátricos a los que se les realizó queratoplastia penetrante en el Hospital de San José, en Bogotá, Colombia. Diseño: Estudio observacional descriptivo, retrospectivo, serie de casos. Método: Se evaluaron 14 ojos de 12 pacientes menores de 16 años a quienes se les realizó queratoplastia penetrante entre los años 1999-2014. Se hizo una revisión de la literatura sobre etiología, manejo quirúrgico, seguimiento y sobrevida de injerto. Resultados: De los 14 ojos estudiados 8 ojos (57,1%) tenían patología congénita con injerto claro en 6 ojos (75%) entre los 3 y 9 meses, 3 ojos (21,4%) tenían etiología traumática, de estos, todos los injertos permanecieron claros en un rango de 3 meses a 11 años y 3 ojos (21,4%) tenían leucomas, queratitis o inminencia de perforación, de estos el injerto permaneció claro entre los 3 y 18 meses. Se encontró una mejoría de visión en 8 de los ojos evaluados (57,1%). Las complicaciones encontradas en estos pacientes fueron: glaucoma en 5 ojos (35.7%), falla de injerto en 6 ojos (42.8%), rechazo endotelial en 7 ojos (50%) y desprendimiento de retina en 1 ojo (7.14%). Conclusión: En el estudio, la mejoría visual fue ligeramente menor a la reportada en la literatura. Las complicaciones presentadas fueron principalmente rechazo endotelial y falla de injerto, lo que difiere de la literatura donde la catarata es la principal complicación.

Purpose: To describe visual results and complications in a case series of paediatric patients who underwent penetrating keratoplasty at Hospital de San José in Bogotá, Colombia. Design: Observational, descriptive and retrospective study, series of cases. Method: 14 eyes of 12 patients under 16 years (2 months - 16 years) who underwent penetrating keratoplasty in Hospital de San Jose from 1999 to 2014 were evaluated. A literature review of etiology, surgical management, monitoring and graft survival of pediatric patients was done. Results: Of the 14 eyes studied, 8 eyes (57.1%) had congenital pathology with clear graft in six eyes between 3 and 9 months, 3 eyes (21.4%) had traumatic aetiology, of these, all graft s remained clear in a range of 3 months to 11 years and 3 eyes (21.4%) had leucoma, keratitis or impending perforation, of these, the graft remained clear between 3 and 18 months. An improvement in vision was found in eight of the evaluated eyes (57.1%). The complications found in these patients were: glaucoma in 5 eyes (35.7%), graft failure in 6 eyes (42.8%), endothelial rejection in 7 eyes (50%) and retinal detachment in 1 eye (7.14%). Conclusion: In our study, the visual improvement was slightly lower than that reported in the literature. The complications presented were mainly endothelial rejection and graft failure, which differs from the literature where cataract is the main complication.

Modificaciones corneales posqueratoplastia penetrante óptica / Corneal changes after penetrating optical keratoplasty

Objetivo: determinar las modificaciones de la córnea donante en el primer año de la posqueratoplastia. Métodos: se realizó un estudio descriptivo, longitudinal y prospectivo de serie de casos en 45 pacientes. Para el procesamiento de las variables se utilizó la prueba de Chi cuadrado con corrección de Yates asociada a pruebas de rangos con signos de Wilcoxon y la prueba de probabilidades exactas de Fischer. Resultados: el diagnóstico más frecuente fue la queratopatía bullosa (35,5 por ciento). La pérdida celular anual fue de 22,8 por ciento; el astigmatismo oblicuo con 61,5 por ciento y la media del cilindro queratométrico de 5,96. En microscopia confocal encontramos ausencia de fibras nerviosas (86,7 por ciento), presencia de queratocitos activados (22,2 por ciento) y haze (11,1 por ciento). Los injertos transparentes correspondieron al 82,2 por ciento. Observamos queratocitos activados en 80 por ciento de córneas no transparentes. El 33,3 por ciento de los leucomas corneales se opacificaron. La complicación más frecuente fue el glaucoma secundario (33,3 por ciento). El 100 por ciento de las úlceras corneales bacterianas evolucionaron a fallo del injerto. Conclusiones: la córnea posqueratoplastia presenta una pérdida celular endotelial anual de 22,8 por ciento, astigmatismo oblicuo, cilindro queratométrico entre 3-6 dioptrías, presencia de queratocitos activados y haze corneal como factores pronósticos de pérdida de transparencia del injerto. El leucoma corneal posúlcera, la queratopatía bullosa como diagnóstico preoperatorio y la úlcera corneal bacteriana como complicaciones provocan pérdida de transparencia del injerto(AU)

Objective: to determine the changes in the donor cornea after one year of keratoplasty. Methods: prospective, longitudinal and descriptive case series study conducted in 45 patients. For variable processing, the study used Yate's corrected Chi-square test associated to Wilcoxon's range test and to Fisher's exact test. Results: the most common diagnosis was bullous keratopathy (35.5 percent). The annual cell loss was 22.8 percent; oblique astigmatism with 61.5 percent and the mean of the keratometric cylinder was 5.96 percent. Using the confocal microscopy, we found lack of nervous fibers (86.7 percent), presence of activated keratocytes (22.2 percent) and haze (11.1 percent). Transparent grafts represented 82.2 percent. Activated keratocytes were observed in 80 percent of non-transparent corneas. In the study, 33.3 percent of corneal leukomas showed opacification. The most common complication was secondary glaucoma (33.3 percent). All the bacterial corneal ulcers evolved into failed graft. Conclusions: after keratoplasty, the cornea showed annual endothelial cell loss of 22.8 percent, oblique astigmatism, 3-6 diopter keratometric cylinder, presence of activated keratocytes and corneal haze as prognostic factors of loss of graft transparency. The post-ulcer corneal leukoma, bullous keratopathy as preoperative diagnosis and bacterial corneal ulcer as main complication cause loss of graft transparency(AU)

The Efficacy of Low-Dose Systemic Cyclosporine for Graft Failure after Penetrating Keratoplasty in High-Risk Group

PURPOSE: To investigate the effect of low-dose systemic cyclosporine A (CsA) in preventing graft failure after high-risk penetrating keratoplasty (PKP). METHODS: In this retrospective study, 36 eyes of 25 patients who underwent PKP were evaluated. At 24 months postoperatively, the failure rate in the CsA group (n = 19) was compared to the control group (n = 17). For subgroup analysis, the failure rate in the CsA group (n = 9) and control group (n = 9) was compared in patients who underwent a repeat PKP. The patients' side-effect profile was also collected. RESULTS: The median follow-up in the CsA group was 32.8 months and 28.9 months in the control group. Graft failure occurred in 31.6% CsA patients and in 68.4% control patients (p = 0.311). In patients with repeat PKP, the failure rate in the CsA group was significantly lower than the control group (22.2% vs. 77.8%, p = 0.018). In one case (5.26%), CsA was discontinued due to gastroinstestinal discomfort. CONCLUSIONS: Low-dose CsA was not beneficial compared to conventional therapy in high-risk PKP patients. However, in the repeat PKP subgroup, the incidence of graft failure was lower with low-dose CsA than with conventional therapy. Although further study is necessary, adding low-dose CsA might be beneficial for repeat PKP patients.

Isolated stromal type corneal graft rejection, a case report / 国际眼科杂志(Guoji Yanke Zazhi)

penetrating keratoplasty was done.Isolated stromal graft rejection was noticed 3 weeks after penetrating keratoplasty,which was confirmed on histopathology.Repeat penetrating keratoplasty 6 months later also had same fate.Diagnosis and management of isolated stromal graft rejection is a very challenging situation.

Indicações de transplante de córnea no Hospital São Geraldo da Universidade Federal de Minas Gerais / Indications for penetrating corneal graft at the São Geraldo Hospital of Minas Gerais Federal University

OBJETIVO: Confrontar com a literatura os dados relacionados à idade, sexo e indicação dos transplantes penetrantes de córnea efetuados no Hospital São Geraldo da Universidade Federal de Minas Gerais (UFMG), de janeiro de 1999 a dezembro de 2005. MÉTODOS: Realizou-se estudo retrospectivo de 887 ceratopatias penetrantes, com dados obtidos dos arquivos da Central Estadual de Notificação de Minas Gerais, MG Transplantes, e dos prontuários dos pacientes do Departamento de Córnea do Hospital São Geraldo. Os dados analisados foram: idade, sexo e diagnóstico pré-operatório das alterações corneanas. As indicações de transplante do período de janeiro de 1999 a junho de 2002 foram comparadas as de julho de 2002 a dezembro de 2005. RESULTADOS: A média da idade dos pacientes foi de 48,3 anos, variando de 4 meses a 97 anos. As principais indicações de transplante penetrante de córnea foram: lesão ulcerativa (34,95 por cento), ceratocone (16,35 por cento), ceratopatia bolhosa do psedofácico (16,01 por cento), leucoma (14,09 por cento), falência primária (7,89 por cento), rejeição (5,64 por cento), distrofia endotelial de Fuchs (1,92 por cento), outras distrofias (1,47 por cento), causa indeterminada (1,23 por cento) e outras causas (0,45 por cento). CONCLUSÃO: A principal indicação de transplante foi para úlcera de córnea em vias de perfuração ou perfurada, responsável por 310 ceratopatias penetrantes. As indicações eletivas mais frequentes de transplantes foram para ceratocone, ceratopatia bolhosa do psedofácico e leucoma, com o crescimento das indicações para ceratopatia bolhosa do psedofácico no período. Mesmo com um aumento significativo no número de transplantes realizados, estratégias que busquem reduzir a alta incidência de ceratopatias penetrantes emergenciais decorrentes de úlceras corneanas devem ser implantadas.

PURPOSE: To determine and compare with the literature data related on age, sex and the main indications for penetrating keratoplasty at the São Geraldo Hospital of Federal Universidade of Minas Gerais (UFMG), from january 1999 until december 2005. METHODS: A retrospective analysis was performed using data from 887 patients submitted to corneal transplantation from january 1999 until december 2005. These data were obtained from the archives of the Central Notification of State of Minas Gerais, MG-Transplantes database, and from the medical records of the São Geraldo Hospital Corneal Department. The data collected were: age, gender and preoperative diagnosis of corneal diseases. A comparative analysis of the most common indications from january 1999 until june 2002 and from july 2002 until december 2005 was also performed. RESULTS: The mean age of patients was 48.3 years, ranging from 4 months to 97 years. The most common corneal graft indications were ulcerative conditions (34.95 percent), keratoconus (16.35 percent), bullous keratopathy (16.01 percent), leukoma (14.09 percent), primary graft failure (7.89 percent), graft rejection (5.64 percent), Fuchs dystrophy (1.92 percent), other dystrophies (1.47 percent), undetermined causes (1.23) and other causes (0.45 percent). CONCLUSION: The main indication for penetrating keratoplasty was corneal ulcer which was almost perfured or perfured, responding for 310 transplants (34.95 percent). There was a substantial increase in the frequency of pseudophakic bullous keratopathy on the studied period. Even though, a significant increase in the number of corneal transplants, new strategies must be implanted to decrease the number of PK for ulcerative conditions.

Comparison of Graft Rejection of First Eyes and Second Eyes after Bilateral Penetrating Keratoplasty

PURPOSE: To compare graft rejection of the first and second eyes after bilateral penetrating keratoplasty. METHODS: We performed a retrospective review of the cases of 16 patients who underwent bilateral penetrating keratoplasty. Nonparametric Kaplan-Meier survival analysis was used to account for variable follow-up among patients. RESULTS: The mean age of the 16 patients (12 M, 4 F) was 39.1 years. Mean follow-up was 89.8 months after surgery in the first eye and 42.8 months after surgery in the second eye. The average time interval between surgery on the first and second eyes was 47.0 months. The indications for surgery were keratoconus (37.5%), corneal dystrophy (25.0%), pseudophakic bullous keratopathy (12.5%), band keratopathy (12.5%), and inflammatory corneal opacity (12.5%). Endothelial rejection occurred in five of the first eyes but was treated successfully, remaining clear until the last follow-up. Endothelial rejections were seen in five of the second eyes, two of which failed. Survival analysis of endothelial rejection showed no significant difference between the first and second eyes; however, survival analysis of the graft failure showed a decreased survival rate of the second eyes compared with that of the first eyes. The best corrected visual acuity at the last follow-up of the second eyes seemed to be worse than that of the first eyes. CONCLUSIONS: Survival analysis of the endothelial rejections showed no significant difference between the first and second eyes. Survival analysis of the graft failure showed decreased survival rate of the second eyes. At the last follow-up the best corrected visual acuity of the second eyes appeared to be worse than that of the first eyes.

Clinical and Histology Findings of Corneal Graft Safety Ring Implanted in Rabbit Cornea

PURPOSE: We developed corneal graft safety ring for improving of penetrating keratoplasty success rate and minimizing the refractive error, and evaluated its stability in the rabbit cornea. METHODS: Following circular corneal incision (depth: 200 microgram, diameter: 7.5 mm) with 7.5 mm Hess-Burg barron vaccum trephine, corneal stroma was dissected toward the corneal center with 6.5 mm diameter. After insertion of the corneal graft safety ring (diameter: 6.0 mm, thickness: 0.15 mm), we examined gross and histologic findings of the rabbit cornea at postoperative 1week, 1month, 3months. RESULTS: The corneal graft safety ring was maintained stable in rabbit cornea for 3months grossly. Histologic finding around corneal graft safety ring showed inflammatory cells and neovascularization which was increased by 1month, and thereafter decreased markedly and maintained stable. CONCLUSIONS: Corneal graft safety ring implantation seemed to be an amenable procedure for improving penetrating keratoplasty outcome.

Immunology study of chronic corneal allograft dysfunction after penetrating keratoplasty / 眼科

Objective To study the expression of immune and non-immune related cytokine in corneal grafts of chronic graft dysfunction after penetrating keratoplasty and reveal the possible mechanism of it.Design Clinical experimental study.Participants Including two groups.In chronic corneal allograft dysfunction(CCAD) group,corneas of 8 patients fulfilling the diagnostic criteria for CCAD who underwent repeated PK operation.Three normal corneas supplied by Shandong provincial eye bank of China were used as control group.Methods The conreal graft were analyzed by immunohistochemical studies.Moreover,the comprehensive analysis was carried out combining the patient's clinical data.Main Outcome Measures CD4~+,CD8~+,F4/80,TGF-?,bFGF and?-SMA in cornea. Results The results of immnunohistochemical studies showed that compared with normal corneas,full-thickness corneal grafts of eight corneas which underwent repeated PK operation had no CD4~+ and CD8~+ T lymphocyte infiltration.F4/80 positive inflammatory cells were more abundant near the stroma of five corneal grafts which underwent once PK operation.Full-thickness corneal grafts of other three corneas which underwent no immune rejection had no F4/80 positive inflammatory cells.The TGF-?positive inflammatory cells were more abundant near the epithelium and stroma of all corneal grafts.The moderate bFGF positive inflammatory cells were present in stroma of all corneal grafts.The?-SMA positive inflammatory cells were more abundant near stroma and the elastic layer of all corneal grafts.Conclusions After PK operation,the results of immnunohistochemical studies of the corneal graft which underwent CCAD showed that there is no evidence of clinical acute rejection.The abnormal expression of antigen presenting cells and non-immune cell specific factors suggest that immune or non-immune factors maybe involve in the occurrence and development of CCAD.