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Lamellar corneal grafts, both anterior and posterior, are rapidly taking over as procedures of choice for several indications requiring corneal transplantation. Despite the promised advantages of lamellar procedures, worldwide, penetrating keratoplasty (PK) remains the predominant procedure. In the future, even when the practice of PK diminishes, its consequences among those who have had the procedure will continue to be encountered for quite a while thereafter. Discounting primary graft failure, there are three main issues that have dogged PK ever since its inception. These are immune-mediated rejection, spherical and astigmatic refractive errors and a weak wound for the rest of the patient’s life. These are intricately inter-related, as interventions to deal with any one can affect the other(s). In this issue, Jeganathan et al report on a retrospective review of 947 consecutive patients who had received a PK. Of these, 5.4% required re-suturing. Individuals who required PK for microbial keratitis had a higher incidence of re-suturing (12%) compared with those with keratoconus (10%) and endothelial decompensation (2.5%). The commonest cause for re-suturing was wound dehiscence (43%) either traumatic or spontaneous. Spontaneous wound dehiscence occurred at a mean of 18.8 months post-PK (following suture removal), highlighting the perpetual weakness of the wound (see page 893).1
Various strategies have been adopted to combat rejection, of which topical steroid medication remains the mainstay. This must be an important factor that affects the strength of the wound at the graft host junction, as it is often administered for a year or more.2
Much attention has focused on suture material and suturing techniques to control postgraft astigmatism and influence wound quality. Suture materials act as “foreign bodies” capable of inciting inflammation, attracting new vessels, acting as a nidus for infection and consequently affecting the wound-healing response, often adversely.3 Biodegradable material such …
Competing interests: None.