opth 22959 outcome of penetrating keratoplasty in corneal ulcer a sing 090211

8/3/2019 OPTH 22959 Outcome of Penetrating Keratoplasty in Corneal Ulcer a Sing 090211

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Clcal Optalmoloy 2011:5 1265–1268

Clinical Ophthalmology  Dovepress

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Op Accss Full Txt Atcl

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 sokab_@yaoo.com

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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