Management of Failed Penetrating Keratoplasty: A New OCT-Based Protocol

Jatin Ashar1

1Mumbai Eye Care, Cornea and LASIK Centre1The Perfect Vision Laser LASIK Centre

NO FINANCIAL DISCLOSURES

IntroductionManagement options for failed penetrating

keratoplasty include repeat penetrating keratoplasty, Descemet’s stripping endothelial keratoplasty or keratoprosthesis

Management of failed penetrating keratoplasty is technically challenging and numerous issues have to be addressed related to the type of surgery, prediction of surgical surprises, graft size and need of additional surgery

A pre operative evaluation using anterior segment OCT may help in avoiding complications and improving outcomes

Purpose To evaluate the role of Anterior OCT in

management of failed graft

440 graft host sections of 55 failed grafts were analyzed using AS-OCT(Visante, Carl Zeiss, Germany)

Malapposition were categorized as gapes, graft or host steps, ledge, protrusion hills or tags

Material & Methods

ResultsSmooth posterior graft host junction (3) allowed

larger or same size DSEK/PK graft

Anterior malapposition(3) necessitated repeat PK

Irregular posterior wound malaaposition 17 cases (2 step, 1 protrusion, 1 gap, 13 ledge) needed larger PK/ smaller DSEK graft

Extensive synechiae >180 degrees in 3 cases and less than 180 degrees synechiae were noted in 4 cases

Graft Sizing

Case 1: 60/M Keratoplasty for corneal scar 4 years backGraft failure secondary to graft rejectionPlan: Repeat keratoplasty

Case 2: 71/FKeratoplasty Graft failure Plan: Repeat keratoplasty

Graft size same as previous graft

Graft Sizing

32/FOperated large PK 8 months back, Failed graft with PED

Graft size smaller than previous graft

67/MOperated PK followed by cataract surgery elsewhere

Graft larger than previous PK

Conclusion AS OCT provides useful information about the

graft host junction and anterior chamber structures after PK that may be useful in anticipation of problems during repeat surgery (DSEK/PK) (need for synechiolysis, available space in the anterior chamber for DSEK, glaucoma device placement and need for glaucoma surgery), graft sizing (step, ledge configurations- smaller/same sized DSEK graft, smooth configuration- larger sized DSEK graft)/ malapposed posterior wound –avoid smaller repeat graft