[Penetrating keratoplasty in high-risk children: prevention of graft rejection].

PURPOSE: To evaluate the efficacy of prolonged courses of systemically administered subtherapeutic Metipred and cyclosporine in prevention of graft rejection in high-risk children. MATERIAL AND METHODS: The study included 27 children at high risk of graft rejection due to re-keratoplasty (n = 8), limbo-keratoplasty for corneal staphyloma (n = 4), or transplantation into vascularized corneal bed (n = 15). All patients were divided into two groups--the study group (n =11) and the control group (n = 16). In order to evaluate the efficacy of two different prevention schemes, the occurrence of graft rejection, rejection crises, and crisis-associated clouding of the transplant was analyzed. RESULTS: The occurrence of transplant opacity was two times lower in the Metipred-cyclosporine group than in the conventional prevention group. Kaplan-Meier one-year survival of the transplant was 53% in the study group and 27% in the control group. Two-year survival rate difference appeared even more significant--53% and 18% correspondingly. CONCLUSION: It is clinically shown that subtherapeutic use of Metipred and cyclosporine decreases the occurrence of rejection crises and transplant failure almost by half in high-risk patients as compared with topical corticosteroids; at the same time the side effects of systemic immunosuppression are not substantial. Thus, the suggested prevention scheme allows to perform keratoplasty and expect a clear transplant in children who previously were considered inoperable, i.e. with total vascularized corneal opacity, giant staphylomas, and corneal burns.

[Keratoconus in children with retinopathy of prematurity (clinical cases)].

2 cases of keratoconus in children with retinopathy of prematurity (RP) developed in eyes with severe retinal scarring as an outcome of RP, but initially clear cornea and normal anterior chamber depth. In one case keratoconus was acute and resulted in visual loss in the only seeing eye and required surgical treatment. In another case kertoconus developed in the eye with residual light perception, had no subjective symptoms, was not acute and was stabilized using nonsurgical treatment.

[Congenital corneal staphylomas in children].

Clinical manifestation, results and outcomes of surgical treatment were studied in children with very rare anomaly of cornea and anterior segment. Symptoms and signs, histological findings are described in details, results of ophthalmoscopy, ultrasound biomicroscopy and maternal ophthalmotrophic infections are studied in children with corneal staphylomas.

[Experience in penetrating keratoplasty in children: graft survival, functional results and risk factors]. / Opyt skvoznoi keratoplastiki u detei: vyzhivaemost' transplantata, funktsional'nye rezul'taty, faktory riska.

Penetrating keratoplasty in children is related with a labor-consuming process of follow-up and care as well as with a high risk of graft rejection and a moderate vision improvement. Nonetheless, keratoplasty has been and still remains a surgery of choice due to a lack of an alternative procedure; its technique and results have been gradually promoted in practice. The authors analyzed 112 keratoplasties in childhood-age corneal opacifications of different types. The graft survival amounted to 71%, 61% and to around 55% after 1, 2 and 5 postoperative years, respectively. Neovascularization, glaucoma, repeated keratoplasty, an original vitreous pathology, an expanded surgical scope (reconstructions) etc. were attributed to risk factors. The visual acuity improved by more than 0.02 in 54% of cases; it remained unchanged or worsened in 22% of cases and it could not be assessed in 24% of cases. The best results were achieved in a group of patients with acquired corneal opacifications of the nontraumatic nature; the worst results were observed in congenital anomalies of the anterior eye segment. Finally, the success of penetrating keratoplasty in children was ensured through a careful selection of patients, an accurate surgical technique and through a fast treatment of postoperative complications.

[Postoperative complications of penetrating subtotal keratoplasty in children]. / Posleoperatsionnye oslozhneniia skvoznoi subtotal'noi keratoplastiki u detei.

Accordingly to experience of corneal transplantations during 1981-2001 in the children's clinic of the Helmholz Moscow Research Institute of Ocular Diseases the authors present the clinical picture, rate, prognostic value and modes of correction of postoperative complications after keratoplasty. A retrospective study analyzed the incidence of complications after 94 penetrating keratoplasties performed in 82 children aged from 10 months to 14 years in 89 eyes for congenital corneal opacity (n = 22) or corneal opacity caused by trauma (n = 40) or inflammation (n = 20). 60 (73%) within 1 year after operation developed different reactions and complications due to transplant failure in 41 (44%) cases. Among them there were graft rejection episodes (34%), anterior synechiae and retrocorneal membrane formation (17%), donor corneal neovascularization (11%), elevated intraocular pressure (11%). There were a few cases with shallow anterior chamber, hyphema/hemophthalmos, retinal detachment, primary graft failure, corneal ulcer, suture infiltrates and abscesses. Subatrophy of the eye was an outcome in 3 cases. The development of complications after penetrating keratoplasty is determined mainly by the physiology of children, age, severity of underlying and concomitant pathology of the eye. Nevertheless, the odds of donor tissue for transparent graft survival increase if such complications are detected and removed.

[Results of optic reconstructive interventions in children with ocular injuries]. / Rezul'taty optiko-rekonstruktivnykh vmeshatel'stv pri travmakh glaza u detei.

Optic reconstructive interventions were carried out in 36 children with ocular injuries aged 3-14 years. Perforating keratoplasty was combined with measures aimed at repair of the normal anatomic status of the eye and the transparency of its optic media. Microsurgical interventions were performed for penetrating corneal wounds in 27 cases, for penetrating corneoscleral injuries in 8, and for eye contusion in 1 case. The patients were followed up for 1 year after surgery. Taking in of donor cornea, time course of visual acuity, intra- and postoperative complications, and the risk factors of the graft failure were evaluated. Transparent healing of donor cornea was observed after 1 month in 94% cases and after 1 year in 60%. In the immediate postoperative period, vision improved in 32 patients, deteriorated in 1, and did not change in 3 patients. In 56% children visual acuity with correction of 0.05 diopters and higher was attained, while before the intervention the predominant (in 80% children) variant was pr. certae. Among the complications, the most incident were graft rejection crises and secondary glaucoma liable to conservative therapy. Vitreoretinal injury is one of the unfavorable factors fraught with the graft failure. Hence, perforating keratoplasty is an effective and obligatory surgical procedure ensuring sufficient visual rehabilitation in the majority of children with severe ocular injuries.