Corneal transplantation in young children with congenital hereditary endothelial dystrophy. Multicenter Pediatric Keratoplasty Study.

PURPOSE: To describe the surgical success rate and visual results of penetrating keratoplasty in a series of young children with congenital hereditary endothelial dystrophy and to summarize the current literature on outcomes of keratoplasty for congenital hereditary endothelial dystrophy, with particular attention to the timing of surgery. METHODS: The authors conducted a retrospective study of children aged 12 years and younger who underwent penetrating keratoplasty between 1975 and 1994 at four participating eye centers, and who were followed for at least 6 months postoperatively. For this report, 21 corneal transplants performed in 16 eyes of nine patients with congenital hereditary endothelial dystrophy were studied. Patients' median age at the time of first keratoplasty was 40 months (range, 3 months to 10 years). RESULTS: During a mean follow-up period of over 70 months (range, 6 to 240 months), 11 (69%) of 16 eyes retained full graft clarity. The 2-year survival rate of first grafts was 71% (95% confidence interval, 47% to 95%). Postoperative visual acuity improvement of 1 or more Snellen lines was seen in five of 10 eyes in which the patients were old enough for accurate assessment of visual acuity; however, just four of these 10 eyes attained a visual acuity of 20/200 or better. CONCLUSIONS: Penetrating keratoplasty for congenital hereditary endothelial dystrophy in children has a reasonable chance of surgical success when performed at a young age; however, the prognosis for improved visual acuity in children appears to be more guarded. Decisions on the timing of surgical intervention for congenital hereditary endothelial dystrophy should be made on a case-by-case basis. Although the threat of irreversible amblyopia in untreated eyes and good surgical success rates even among very young children argue for the consideration of relatively early surgical intervention in the most severely affected cases, there is evidence to support delaying surgery in some cases.

Corneal transplantation in children with Peters anomaly and mesenchymal dysgenesis. Multicenter Pediatric Keratoplasty Study.

OBJECTIVE: The purpose of the study is to describe graft and visual outcomes of penetrating keratoplasty among young children with Peters anomaly and associated mesenchymal dysgeneses. DESIGN: The design was a multicenter retrospective analysis of the indications and outcome in pediatric keratoplasty. PARTICIPANTS: The records of all children aged 12 years and younger who underwent penetrating keratoplasty for mesenchymal dysgenesis between January 1975 and May 1993 at the participating centers were reviewed. MEASURES: The data were analyzed regarding graft survival and postoperative visual acuity. RESULTS: Forty-seven corneal transplants in 36 eyes of 29 patients with mesenchymal dysgenesis were studied. The majority of eyes operated on (30) had Peters anomaly (83%). Patients' mean age at the time of keratoplasty was 7 months. After a mean follow-up period of 38 months, 61% of eyes retained full graft clarity. One and 3-year survival rates were 79% (95% confidence interval [CI] = 65%-93%) and 62% (95% CI = 45%-79%), respectively. Postoperative corneal ulcers/nonhealing epithelial defects (P = 0.03), and additional noncorneal surgical procedures at the time of transplantation (P = 0.05) were associated with graft failure. Provision of postoperative optical aids (P = 0.01) was associated with better postoperative visual acuity levels. CONCLUSIONS: Penetrating keratoplasty for Peters anomaly and related mesenchymal dysgeneses in young children has a reasonable chance of success during the critical years of visual maturation and is associated with satisfactory visual results in one third to half the cases. The data suggest that complicated cases requiring additional surgical procedures have a worse prognosis.

Povidone-iodine (betadine) in the treatment of experimental Pseudomonas aeruginosa keratitis.

Topical 5% povidone-iodine for the treatment of corneal ulcers was observed in Sierra Leone, West Africa by one of us (D.J.D.). To test the efficacy of topical 5% povidone-iodine for infectious keratitis, experimental Pseudomonas aeruginosa keratitis was induced in 12 rabbits by first abrading the central 3 mm of corneal epithelium. Thirty milliliters of broth of P. aeruginosa strain ATCC 27835 (1.8 x 10(7) viable bacteria) was dropped twice on the wounded cornea. After 22 h, all corneas were clinically infected. Eight rabbits were treated with 5% povidone-iodine solution and four with 0.9% NaCl solution. All were given hourly drops. Twenty-four hours after treatment began, the central 8-mm button of the infected cornea was excised, homogenized, and serial dilutions plated onto MacConkey agar. The total number of viable Pseudomonas organisms was calculated. The treatment group had 5.2 +/- 0.4 CFUs (colony-forming units) per cornea. The control group had 4.8 +/- 0.4 CFUs per cornea (p = 0.11). The clinical scores (Hobden grading system) were 6.9 +/- 1.5 for the treated group and 7.3 +/- 2.5 for the control group (p = 0.74). There was no statistical difference between the treated and control groups. Povidone-iodine (5%) is not effective in the acute treatment of P. aeruginosa keratitis in this rabbit model.

Outcome of penetrating keratoplasty after ocular trauma in children.

OBJECTIVE: To characterize the outcome of penetrating keratoplasty in children for the visual rehabilitation of corneal injury. DESIGN: Multicenter retrospective study of the outcome of penetrating keratoplasty for ocular trauma in children. PATIENTS: All children aged 12 years and younger who underwent penetrating keratoplasty between January 1975 and May 1993 for penetrating corneal (n = 18) or corneoscleral (n = 3) trauma and nonpenetrating corneal trauma (n = 1). MAIN OUTCOME MEASURES: Graft survival and postoperative visual acuity improvement. RESULTS: Twenty-two children underwent 25 penetrating keratoplasties during the study period. Graft survival was 84% at 1 year and 70% at 2 years after surgery. Visual acuity improved in 15 (83%) of the 18 children with measurable preoperative and postoperative vision. Children with posterior segment injury before keratoplasty were less likely to maintain a clear graft (P = .04) and less likely to have improved vision postoperatively (P = .06). Children who received amblyopia treatment and appropriate optical correction postoperatively were more likely to have visual improvement than those who did not (P = .02). CONCLUSIONS: Penetrating keratoplasty for corneal trauma is generally a successful operation in the pediatric age group, with visual improvement seen in more than four fifths of cases. Graft survival and visual outcome are best in patients with trauma limited to the anterior segment. Aggressive postoperative refractive correction and amblyopia management also appear to contribute to a better visual outcome in pediatric keratoplasty.

Tissue utilization at the Minnesota Lions' Eye Bank.

The purpose of this study was to examine the utilization of corneas procured by the Minnesota Lions' Eye Bank to determine why corneas were excluded from transplantation and to identify methods to safely increase the number of tissues made available for transplantation. We performed a retrospective review of the eye bank charts of 2,382 corneas evaluated by the Minnesota Lions' Eye Bank between December 1, 1992 and November 30, 1993. During that time 748 corneas (31%) were made available for transplantation; 1,597 (67%) were directed toward research or training. Thirty-seven corneas (1.5%) were disposed of for safety reasons. Six hundred and sixty of the corneas which were excluded from transplantation (40%) were excluded for a donor aged over 75 years. Three hundred and ninety-one corneas (24%) were rejected because of a contraindication in the donor's past ocular or medical history. Another 395 corneas (24%) were excluded for poor tissue quality. The most common reason for exclusion of tissue based on tissue quality was abnormalities seen on specular microscopic examination (200 corneas). Of interest, only 14 corneas were rejected for low endothelial cell counts. This review of our tissue evaluation process has led us to reevaluate and change our policy regarding exclusion of corneas for epithelial defects and arcus senilis. These data suggest that further evaluation of the abnormalities seen on specular microscopic examination and their validity as exclusion criteria should be undertaken. Other areas for further evaluation are how to improve the timeliness of tissue procurement and whether excluding all tissues over age 75 years and all postsurgical eyes is valid.

The indications for and outcome in pediatric keratoplasty. A multicenter study.

PURPOSE: A multicenter study was undertaken to delineate the indications for and outcome of pediatric keratoplasty. METHODS: The authors retrospectively studied 164 grafts in 131 eyes of 108 children younger than 12 years of age, with an average follow-up of 45 months. Multivariate linear and logistic regression was performed to evaluate potential risk factors for poor visual outcome and graft failure. Graft survival was depicted in terms of the Kaplan-Meier survival curve. RESULTS: Corneal opacities were grouped into three diagnostic categories: congenital (64%), traumatic (17%), and acquired nontraumatic (19%) opacities. Overall graft survival was 80% at 12 months and 67% at 24 months postoperatively. There was no significant difference in retention of clarity among diagnostic groups. Vitrectomy-lensectomy, regrafts, and postoperative complications were associated significantly with poor allograft survival. Eighteen percent of all eyes had worse vision at the time of the last visit than preoperatively. Amblyopia treatment was the only independently significant prognosticator for visual improvement after surgery. Timing of keratoplasty was not demonstrated to be associated with visual outcome. Visual acuity in 33% of eyes that could be quantified was better than 20/200 at the last visit, whereas 62% of eyes retained full graft clarity. CONCLUSION: The authors conclude that keratoplasty can be successful in most children, especially when combined with appropriate amblyopia management.

Antiviral therapy after penetrating keratoplasty for herpes simplex keratitis.

OBJECTIVE: To assess the efficacy of prophylactic topical antiviral therapy after penetrating keratoplasty for herpes simplex keratitis in the postoperative period and during the treatment of allograft rejection episodes with topical steroids. We used these data to make predictions of the sample size required to perform a prospective study of prophylactic oral acyclovir in the postoperative period. DESIGN: Retrospective review. SETTING: A university referral cornea service. PATIENTS: One hundred thirty-two consecutive penetrating keratoplasties for herpes simplex keratitis in 119 eyes of 118 patients. Only four grafts were performed in actively inflamed eyes. INTERVENTIONS: Sixty-six (52%) of the grafts performed in quiescent eyes received prophylactic postoperative topical antiviral treatment, three (2%) received oral acyclovir, and 59 (46%) received no antiviral therapy. The mean (+/- SD) duration of antiviral therapy was 12.8 +/- 22.5 months. MAIN OUTCOME MEASURES: Herpetic recurrence, allograft rejection episodes, and graft failure. RESULTS: Multivariate analysis showed that early antiviral use was associated with a decreased risk of herpes simplex keratitis recurrence (relative risk [RR] = 0.44; 95% confidence interval [CI], 0.21 to 0.94; P = .007) and allograft rejection (RR = 0.43; 95% CI, 0.25 to 0.75; P = .002). Graft failure was associated with herpetic recurrence within the first year (RR = 2.25; 95% CI, 1.09 to 4.64; P = .001) and allograft rejection episodes (RR = 2.56; 95% CI, 1.20 to 5.26; P = .003). Using these data, a prospective trial of postoperative oral acyclovir would require between 59 and 112 patients per group. CONCLUSIONS: Postoperative prophylactic antiviral treatment is associated with decreased rates of herpes simplex viral keratitis recurrence and allograft rejection. Early recurrence is associated with an increased risk of graft failure. A prospective study of postoperative oral acyclovir would require a multicentered approach.