Evaluation of Graft Clarity Post-penetrating Keratoplasty

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1 Originl Artile Print ISSN: Online ISSN: X DOI: /ijss/2017/163 Evlution of Grft Clrity Post-penetrting Kertoplsty Nit Shnhg 1, Priy Ptil Choler 2, N Shn 3, Lnin Chen 4, T S Sujth 4 1 Professor n He, Deprtment of Ophthlmology, D. Y. Ptil Meil College & Reserh Centre, Nvi Mumi, Mhrshtr, Ini, 2 Assoite Professor, Deprtment of Ophthlmology, D. Y. Ptil Meil College & Reserh Centre, Nvi Mumi, Mhrshtr, Ini, 3 Senior Registrr, Deprtment of Ophthlmology, D. Y. Ptil Meil College & Reserh Centre, Nvi Mumi, Mhrshtr, Ini, 4 Post-grute Stuent, Deprtment of Ophthlmology, D. Y. Ptil Meil College & Reserh Centre, Nvi Mumi, Mhrshtr, Ini Astrt Introution: Penetrting kertoplsty (PK) is the most ommonly performe metho of ornel trnsplnttion. It is performe for entrl eep opities in the visul xis, kertoonus, n isorers ffeting the ornel enothelium resulting in orne eem n loss of ornel lrity. Mterils n Methos: A prospetive, linil stuy ws rrie out t D. Y. Ptil Meil College, Nvi Mumi, whih inlue 50 ptients who were plnne to unergo full thikness PK for vrious ornel pthologies. Pre-opertive investigtions n exmintions were onute n informe written onsent ws tken efore the proeure. A full thikness PK ws performe. Postopertive follow-up ws one on y 1, y 7, y 28, monthly up to 3 months n 3 monthly up to 1 yer. The post-opertive visul uity, lrity of the grft, n omplitions enountere were ompre. Results: Of the 50 ptients inlue in the stuy, 23 ptients unerwent only PK surgery, 10 ptients unerwent the triple proeure (PK + trt extrtion + introulr lens implnttion), n 17 ptients unerwent PK with other proeures. On susequent follow-up t y 28, there ws ler grft in 41 ptients (82%). There ws epithelil grft rejetion in 1 ptient (2%) of Steven Johnsons Synrome. There ws enothelil grft rejetion in 2 ptients (4%) of virl ornel uler n previous file grft. There ws gluom in 1 ptient (2%). Severe stigmtism ws notie in 24 ptients (48%). At the en of 1 yer, we lost one ptient to follow-up. Among the 49 ptients, there ws ler grft in 35 ptients (70%). There ws gluom in 2 ptient (4%). Severe stigmtism with ler grft ws notie in 6 ptients (12%). There ws enothelil grft rejetion in 10 ptients (20%). Conlusion: The short-term suess n survivl of ornel grfts in this prt of the eveloping worl re resonly goo. By tking re of the pre- n post-opertive ftors responsile for grft rejetion, our stuy hs vlite the normlly epte fts regring outome n survivl of ornel grfts. Age, gener, initions for surgery, ornel grft imeter, n intropertive vitreous loss h no signifint effets on the outome. Key wors: Cornel opity, Cornel trnsplnttion, Cornel uler, Grft lrity, Grft rejetion, Penetrting kertoplsty INTRODUCTION Penetrting kertoplsty (PK) is the most ommonly performe metho of ornel trnsplnttion. It is performe for entrl eep opities in the visul xis, kertoonus, n isorers ffeting the ornel enothelium resulting in orne eem n loss of ornel lrity. It sores over lmellr proeures ue to their steep Aess this rtile online lerning urve n nonvilility of ut tissue t eye nk enters. 1-3 Visul loss in the orne my e the result of eem, opity, srring or n irregulr surfe. PK n yiel exellent visul uity, ut it is more prone to serious introulr omplitions n higher rte of rejetion ompre with the lmellr proeure. It is impertive to wth for signs of grft rejetion or filure Month of Sumission : Month of Peer Review : Month of Aeptne : Month of Pulishing : MATERIALS AND METHODS A prospetive, linil stuy ws rrie out t D. Y. Ptil Meil College n Reserh Centre, Nvi Mumi, from Jnury 2011 to Deemer Corresponing Author: Dr. Lnin Chen, Deprtment of Ophthlmology, D. Y. Ptil Meil College & Reserh Centre, Nerul Setor 5, Nvi Mumi , Mhrshtr, Ini. Phone: E-mil: lnin_hen@hotmil.om Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1 90

2 A totl of 50 ptients who were plnne to unergo full thikness PK for vrious ornel pthologies were inlue in the stuy. Pre-opertive evlution ws one whih inlue the following: 1. Detile history 2. Visul uity on the Snellen s hrt. Pereption of light n projetion of rys (PLPR) were urtely oumente 3. Ojetive refrtion inluing retinosopy n utomte refrtion 4. Automte kertometry 5. Cornel topogrphy y Kertron sout topogrpher 6. Ultrsoun B-sn to rule out funus pthology 7. Introulr lens (IOL) power lultion wherever inite 8. Applntion tonometry y Golmnn s tonometer or tonopen 9. Shirmer s test 10. Cornel sensitivity to rule out the previous herpes infetion. Inlusion Criteri 1. Pseuophki ullous kertopthy 2. Mulr/leuomtous ornel opity involving the visul xis 3. Cornel ystrophies 4. Cornel egenertions 5. Epithelil ingrowth/firovsulr owngrowth 6. Impening ornel perfortion/esemetoele/ ornel perfortion 7. Nonheling ornel uler. Exlusion Criteri 1. Neulrornel opity 2. Cornel opity not involving the visul xis 3. Unfit for surgery ue to systemi illness or eilitting iseses 4. Unwilling for onsent/ptient not omplint/unwilling for follow-up. In situ, orneoslerl rim exision ws one for ll eye ontions, n onor tissue ws ollete in M.K. meium with ll septi preutions. Tissue evlution ws one y slit lmp oservtion n speulr mirosopy. Donor orne of goo enothelil ell ount >2500 ells/u.mm ws otine from the eye nk. A full thikness PK uner lol/generl nesthesi ws one y the sme surgeon on quiet eye fter wellinforme written onsent. Surgil Tehnique Most surgeries were one uner periulr nesthesi with 2 ptients (uner the ge of 18 yers) requiring generl nesthesi. Li stithes were tken with silk suture, n the orne ws expose. Eye speulum ws voie to prevent invertent pressure on the gloe. Fliering ring ws use where inite. The onor orne ws trephine using mnul ornel trephine of size 7.5, 8.0, 8.5, or 9.0 epening on the size of the ornel opity n unerlying ornel pthology. The reipient orne ws trephine using mnul ornel trephine of size 0.5 mm smller thn the ornel trephine use to trephine the onor orne. This isrepny ws to hve well forme nterior hmer (AC) to voi peripherl nterior synehie (PAS) in the ngle leing to seonry gluom, inflmmtion, n vsulriztion. The reipient isese tissue ws seprte using orneoslerl sissors fter trephintion n initil entry with the trephine. A omplete penetrtion of trephine ws voie to prevent injury to the iris n unerlying lens. The iris n lens (ler lens or IOL) were protete with the help of visoelsti sustne (VES) while utting with sissor. In ses of trt, it ws trete y extrpsulr trt extrtion/posterior hmer IOL polymethylmethrylte rigi implnttion open-sky tehnique. The onor orne ws ple on the efet immeitely fter removing the isese reipient orne, n interrupte sutures were tken with 10-0 monofilment nylon t 6, 12, 3, n 9 O lok positions to prevent slerl ollpse with susequent vitreous loss. Therefter, the entire grft ws seure with 16 interrupte sutures with 10-0 interrupte monofilment nylon. A ptent peripherl utton-hole irietomy ws one to prevent postopertive pupillry lok. Before the lst suture, n AC wsh ws given to remove the VES, n the ngle ws swept with n iris repositor to rek ny PAS. AC ws forme with n ir ule, n well-forme AC epth ws ensure. 91 Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1

3 Kertosopi en-point following suturing ws oserve to minimize stigmtism. A topil ntiioti eye rop, ortiosteroi eye rop, n eye ointment tropine were instille, n the eye ws pe. Postopertively, the ptients were strte on the following: 1. Topil ntiioti rops - eye rop moxifloxin 0.5% 4 times/y 2. Topil steroi rops - eye rop prenisolone ette 1% 6 times/y whih ws tpere fter 4 weeks with the introution of yloimmune 0.1%/trolimus 0.03% twie/y 3. Topil lurint rops 4 times/y 4. Eye ointment tropine 1% twie/y 5. Topil ntigluom rops B-loker eye rop timolol 0.5% twie/y 6. Orl ro spetrum ntiioti iprofloxin 500 mg twie/y 5 ys 7. Orl nonsteroil nti-inflmmtory rug ilofen soium 50 mg twie/y 3 ys 8. Orl ortiosteroi prenisolone 1 mg/kg 4 weeks n tpere to mintenne ose of 10 mg over 6-8 weeks. Aitionl tretment ws e epening on the ornel pthology. This inlue, Antiteril tretment with moxifloxin 0.5% 6 times/y with Tormyin 0.3% 6 times/y Topil ylovir 3% eye ointment 5 times/y n orl ylovir 800 mg 5 times/y 7 ys tpere to 400 mg twie/y for 6 months, for ses of ornel uler of virl origin or ptients with non-heling ornel uler with sent ornel senstions Topil mphoteriin B eye rops 0.15% every 1 hourly for ornel ulers of fungl origin. A juiious jugment of tpering ntimiroil n introuing topil steroi to mke therpeuti PK into optil one if possile without retivting infetion in the grft. In se of rise introulr pressure (IOP), treuletomy with mitomyin C ws one efore PK to voi post-pk gluom. However, few ses unerwent treuletomy with mitomyin C post-pk surgery ue to rise IOP. Comine proeures with trt extrtion, IOL implnttion, IOL explnttion, et., were lso inlue in the stuy. Follow-up ws one on y 1, y 7, n y 28. From then on the ptient ws evlute every 3 months up to 1 yer. The following ws exmine t every follow-up: 1. Ojetive refrtion 2. Best-orrete visul uity 3. Kertometry 4. Cornel topogrphy 5. Slit lmp exmintion 6. Introulr pressure 7. Shirmer s test/ter film rek-up time. The grft lrity ws evlute se on slit lmp exmintion looking for the following: 1. Fresh kerti preipittes (KP) 2. Cornel eem 3. Desemet s fols 4. Pigments/loo stin on enothelium 5. Epithelil line 6. Suepithelil hze Krhmer spots 7. Stroml hze 8. Liner stroml opifition Khooust line. Grft lrity ws gre s Gre 4 if grfts were optilly ler with exellent view of iris etils, Gre 2-3 (orerline) if there ws moerte to signifint ornel hze with or without goo view of iris etils, n Gre 1-0 (file) for opque grfts with poor view of iris n nterior segment etils. 11 Goo visul improvement ws efine s postopertive vision improvement two lines on Snellen s ompre with pre-opertive vision, moerte s one line improvement, n No improvement if vision remine sme or worsene. Grft filure ws efine s irreversile loss of optil lrity with the te of onset tken when the ptient presente to orne lini with signs of irreversile rejetion (for 3 months or more) or with file grft. RESULTS The men ge of the ptient ws 48 yers, with the olest ptient s 87 yers n youngest ptient s nine yers. Of the 50 ptients, 32 were femle n 18 were mle. The most ommon initions (Grph 1) for surgery were ornel srring (40%), ullous kertopthy (28%), non-heling ornel uler (16%), n others (16%) (Figures 1 n 2). Of the 50 ptients inlue in the stuy, 23 ptients (46%) unerwent only PK surgery, 10 ptients (20%) unerwent triple proeure (PK + trt extrtion + IOL implnttion), n 6 ptients (12%) unerwent PK with other proeures suh s IOL exhnge, nterior vitretomy, or seonry IOL implnttion (Tle 1). Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1 92

4 Tle 1: Proeure Proeure Numer (%) PK 23 (46) PK+trt extrtion+iol implnttion 10 (20) PK followe y trt extrtion+iol implnttion 3 (6) Treuletomy followe y PK 6 (12) PK followe y treuletomy 2 (4) PK+other proeures 6 (12) PK: Penetrting kertoplsty, IOL: Introulr lens Grph 1: Initions for surgery Pre-opertive visul uity ws worse thn CF 2 m in ll ptients (100%), with only 8 ptients (16%) hving visul uity etter thn PLPR. There ws vitreous loss in 1 ptient uring the PK proeure. A retropupillry iris lw ws implnte in this ptient fter net nterior vitretomy. Itrogeni iris leeing ws seen in 3 ptients. Positive introulr pressure ws experiene in 1 ptient intr-opertively ue to slerl prolpse. An immeite grft plement with 4 nhoring sutures verte vitreous loss. My e Flerring ring oul hve voie this. Grph 2: Outome on y 1 On post-opertive y 1 (Grph 2), the grft remine ler in 23 ptients (46%), ornel eem in 12 ptients (24%), pigments on the enothelium in 8 ptients (16%), hyphem in 1 ptient (2%), n introulr inflmmtion n rise IOP in 6 ptients (12%) (Figure 3). On susequent follow-up t y 28 (Grph 3), there ws ler grft in 41 ptients (82%). There ws epithelil grft rejetion in 1 ptient (2%) of Steven Johnsons synrome. There ws enothelil grft rejetion in 2 ptients (4%) of virl ornel uler n previous file grft. There ws gluom in 1 ptient (2%). Severe stigmtism ws notie in 24 ptients (48%). Grph 3: Outome on y 28 Overll, grfts remine ler t follow-up visits. Gluom or postopertive gluom h no sttistilly signifint effets on grft outome s ll ptients suseptile to gluom unerwent treuletomy with mitomyin C, n ll ptients were strte on post-opertive ntigluom eye rops. At the en of 1 yer (Grph 4), one ptient ws lost to follow-up. Among the 49 ptients, there ws ler grft in 35 ptients (70%). There ws gluom in 2 ptients (4%). Severe stigmtism with ler grft ws notie in 6 ptients (12%). There ws enothelil grft rejetion in 10 ptients (20%) (Figure 4). The post-opertive visul uity t the en of 1-yer follow-up ws etween 6/18 to 6/60 in 38% followe y etter thn 6/18 in 36% on the Snellen s hrt (Tle 2). Grph 4: Outome t 1 yer There is vriety of resons for this. In our series, only one-hlf of our ses were goo prognosis ses suh s ornel ystrophies, kertoonus, et. Few of our ptients re high-risk ses, whih re t inrese immunologil risk of grft rejetion ue to ftors suh s vsulrize ornes, previous grft filure. Seon, most of our ornel olletion is through voluntry eye ontions y home lls, 93 Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1

5 Tle 2: Distriution of pre opertive visul uity on Snellen s hrt Visul uity on Snellen s hrt Numer of ptients (%) >6/18 12 (24) 6/18 6/60 19 (38) CF 5 m to CF 2 m 12 (24) <CF 2 m 7 (14) soli orgn trnsplnts, with short-term survivl rtes (1 yer) s high s 90%. 14 However, the long-term suess rte iminishes to 73% t 5 yers, 60% t 10 yers, n 46% t 15 yers s reporte in ACGR. 15 Reports from vrious grft registries of the evelope ountries show the initions for surgery eing minly kertoonus, other ornel ystrophies, followe y phki n pseuophki ullous kertopthies. 2,3 However, the senrio in eveloping worl is quite ifferent. First, the ptient profile n initions for surgery iffer. Aoring to stuy one in Nepl, ornel srs following infetious kertitis, herent leukoms, n ornel perfortions were the mjor initions for surgery. 16 A stuy one in Ini to nlyze survivl rte of ornel trnsplnts in lrge series shows survivl rtes t 1, 2, n 5 yers for firsttime grfts to e 79.6%, 68.7%, n 46.5%, respetively. 17 They re ifferent from the western stuies essentilly ue to ifferenes in ptient profile, ifferent initions for surgery, ifferenes in methos of storge of ornes, n soioeonomi ftors ffeting helth-re provision. Figure 1: Pre-opertive initions Grft filure is efine s irreversile loss of entrl grft lrity, irrespetive of the visul uity. Grft rejetion ws efine s presene of one or more of the following signs: Mil if there were 1-5 KP, suepithelil infiltrtes inrese ornel thikness without inrese in queous ells. Severe rejetion if >5 KPs, inflmmtory ells in the strom (not ue to infetion), enothelil rejetion line or inrese thikness with queous ells. our onors eing in the ge group 60 yers n ove, with verge qulity of onor tissue n omprtively lower enothelil ell ounts. 12,13 Hospitl Corne Retrievl Progrms more often give higher yiel n younger onor tissue. In ition, mjority of our ptients re illiterte with poor soioeonomi sttus. Hene, post-opertive re n follow-up were mjor hllenge. DISCUSSION Figure 2: Pre-opertive initions Cornel trnsplnt surgery is the most ommonly performe llogrft n is si to e the most suessful Ftors etermining the lrity of grft n e tegorize s: Poor enothelil ount in the onor grft Inition of the grft Therpeuti Stining of the orne Herpes infetion Firovsulr ingrowth Reipient ornel vsulriztion >180 Unontrolle gluom Inflmmtion Ctrt neeing omine proeure Oulr surfe isorers Derese ornel senstions Deilitting iseses Unontrolle ietes mellitus Tuerulosis HIV Collgen vsulr isorers Vitreous loss with vitreous in AC. The stuy ws one in tertiry re enter wherein n eye nk exists. The tissue ws ollete with goo Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1 94

6 Suture infiltrte ws voie y removing loose suture t follow-up. If present then, they were trete with ilute etine rops in ition to the regulr tretment. With this protool, we mnge grft survivl rte 75% of over perio of 1 yer. There re severl limittions to our stuy. We i not ssess in etils the effet of severl onor tissue-relte vriles suh s eth to in situ exision time, preservtion time, ge of the onor, humn leukoyte ntigen mthing, or ABO grouping of onor-reipient. Figure 3: Diffuse slit lmp exmintion photogrph on Dy 1 CONCLUSION The short-term suess n survivl of ornel grfts in this prt of the eveloping worl re resonly goo. By tking re of the pre-opertive n post-opertive ftors responsile for grft rejetion, our stuy hs vlite the normlly epte fts regring outome n survivl of ornel grfts. Age, gener, initions for surgery, ornel grft imeter, n intropertive vitreous loss h no sttistilly signifint effets on the PK outome. Further improvements in eye nking filities, opting hospitl orne retrievl progrm to proure young onor ornes, n etter ptient ounseling to ensure goo follow-up re neee to improve long-term survivl of ornel grfts. REFERENCES Figure 4: Diffuse slit lmp exmintion photogrph t 1 yer enothelil ell ount. The onfouning ftors suh s ry eyes, gluom, inflmmtion, n vsulriztion were ontrolle rigily to voi ny mishp. The sterois were tpere n immunosuppressnts introue to prevent steroi-relte omplitions. A ompetent surgeon i the PK. Most of the ftors ontriuting to grft filure were ontrolle. The ftor ontriuting to grft rejetion seeme to e non-ompline on the ptient prt of frequent follow-up n to putting so mny rops in the eye over long perio. The seon one seeme to e retivtion of herpes infetion in the eye. The epithelil rejetion ws seen in the swith over from sterois to immunosuppressnts. However, it ws well ontrolle with reintroution of sterois. Hene, the itum to introue oth sterois s well s immunosuppressnts n then slowly tpers the sterois. Astigmtism ws seen in ll the ptients. To reue this, we introue kertosopi enpoint uring surgery. At 3 months removl of the steep suture if stigmtism >4D n to ontinue this every 2 weeks till we got the stigmtism elow 3D. With this, the BCVA in ler grft ws lmost lwys etter thn 6/ MDonnell PJ, Enger C, Strk WJ, Stulting RD. Cornel thikness hnges fter high-risk penetrting kertoplsty. Collortive ornel trnsplnttion stuy group. Arh Ophthlmol 1993;111: Cosr CB, Srihr MS, Cohen EJ, Hel EL, Alvim Pe T, Rpuno CJ, et l. Initions for penetrting kertoplsty n ssoite proeures, Corne 2002;21: Coster DJ, Willims KA. The impt of ornel llogrft rejetion on the long-term outome of ornel trnsplnttion. Am J Ophthlmol 2005;140: Hlerstt M, Mhens M, Ghlenek KA, Böhnke M, Grweg JG. The outome of ornel grfting in ptients with stroml kertitis of herpeti n non-herpeti origin. Br J Ophthlmol 2002;86: Rmmurthy S, Rey JC, Vvlli PK, Ali MH, Grg P. Outomes of Repet Kertoplsty for File Therpeuti Kertoplsty. Am J Ophthlmol 2016;162:83-88.e2. 6. Joshi SA, Jgle SS, More PD, Deshpne M. Outome of optil penetrting kertoplsties t tertiry re eye institute in Western Ini. Inin J Ophthlmol 2012;60: Shi WY, Wng X, Xie LX. Clinil stuy on the enothelil immune rejetion fter penetrting kertoplsty. Zhonghu Yn Ke Z Zhi 2005;41: Auou M, Wu T, Evns JR, Chen X. Immunosuppressnts for the prophylxis of ornel grft rejetion fter penetrting kertoplsty. Cohrne Dtse Syst Rev 2015;CD Oto T, Ishiym S, Hyshier T, Mori Y, Nejim R, Miyt K, et l. Twelve-yer follow-up of penetrting kertoplsty. Jpn J Ophthlmol 2016;61: Kene MC, Glettis RA, Mills RA, Coster DJ, Willims KA; for Contriutors to the Austrlin Cornel Grft Registry. A omprison of enothelil n penetrting kertoplsty outomes following file penetrting kertoplsty: A registry stuy. Br J Ophthlmol pii: Bjophthlmol Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1

7 11. Sihot R, Shrm N, Pn A, Aggrwl HC, Singh R. Post-penetrting kertoplsty gluom: Risk ftors, mngement n visul outome. Aust N Z J Ophthlmol 1998;26: Tn DT, Jnrhnn P, Zhou H, Chn YH, Htoon HM, Ang LP, et l. Penetrting kertoplsty in Asin eyes: The Singpore ornel trnsplnt stuy. Ophthlmology 2008;115: e Bourne WM, Nelson LR, Hoge DO. Centrl ornel enothelil ell hnges over ten-yer perio. Invest Ophthlmol Vis Si 1997;38: Willims KA, Muehlerg SM, Lewis RF, Coster DJ. How suessful is ornel trnsplnttion? A report from the Austrlin ornel grft register. Eye (Lon) 1995;9: Willims KA, Lowe M, Brtlett C, Kelly TL, Coster DJ; All ontriutors. Risk ftors for humn ornel grft filure within the Austrlin ornel grft registry. Trnsplnttion 2008;86: Tin GC, Gurung R, Puyl G, Rey HS, Hos CL, Wiemn MS, et l. Penetrting kertoplsty in Nepl. Corne 2004;23: Dnon L, Nuvilth TJ, Jnrthnn M, Rgu K, Ro GN. Survivl nlysis n visul outome in lrge series of ornel trnsplnts in Ini. Br J Ophthlmol 1997;81: How to ite this rtile: Shnhg N, Choler PP, Shn N, Chen L, Sujth TS. Evlution of Grft Clrity Post-Penetrting Kertoplsty. Int J Si Stu 2017;5(1): Soure of Support: Nil, Conflit of Interest: None elre. Interntionl Journl of Sientifi Stuy April 2017 Vol 5 Issue 1 96