Editorial

Penetrating keratoplasty in infants and children

To report the long-term outcomes of Descemet stripping endothelial keratoplasty (DSEK) with suture-assisted donor lenticule insertion performed in different age groups for pediatric patients with congenital hereditary endothelial dystrophy (CHED).

Retrospective case series.

Pediatric patients with CHED who underwent DSEK from January 2010 to January 2016 were enrolled. Patients were divided into 2 groups according to their ages: the infant group and the child group. Long-term clinical outcomes and complications were compared.

Thirty eyes of 16 patients were included: 19 eyes (10 patients) in the child group and 11 eyes (6 patients) in the infant group. The average duration of follow-up was 4.08 ± 1.90 years (range 2.5–8.5 years). Corneal transparency scores of the 2 groups on postoperative day 7 were not statistically different. The average postoperative best-corrected visual acuity (BCVA) in the infant group (logMAR 0.32 ± 0.11) was better than that in the child group (logMAR 0.54 ± 0.20; (P = .01). Thirty-three percent of cases in the child group and 86% of cases in the infant group had postoperative BCVA achieved or better than logMAR 0.4. Average endothelial cell loss in the child group was 31.21% ± 9.17%. Lenticule detachment occurred in 3 cases in the child group.

Improved visual outcomes could be achieved in infant patients with CHED after DSEK without significant complications. Suture-assisted donor lenticule insertion techniques, Descemet membrane stripping, and postoperative sedation are advocated technical points.

To conduct a qualitative description of corneal and glaucoma outcomes in Peters anomaly.

Retrospective case series.

Children with Peters anomaly who presented between 1982–2017 were included. Visual acuity, intraocular pressure (IOP), survival of corneal grafts, and success of glaucoma surgery (defined as IOP of 5–20 mm Hg and no additional IOP-lowering surgery or visually devastating complications) were analyzed.

Fifty-eight eyes of 37 patients (19 males) with Peters anomaly presented at 0.7 ± 1.5 years of age and had a follow-up of 10.2 ± 10.8 years. Twenty-three eyes underwent penetrating keratoplasty (PKP) with an average of 2.0 ± 1.3 grafts per eye. PKP survival at 1 year was 60% (95% confidence interval 41–75%) but decreased at 10 years to 34% (95% confidence interval 18–51%). Thirty-four eyes were diagnosed with glaucoma at 2.8 ± 6.4 years of age. Twenty eyes required glaucoma surgery, and the average number of IOP-lowering surgeries was 2.9 ± 2.0 per eye. Glaucoma drainage devices (15 eyes) had a 53% success rate. Laser cycloablation (9 eyes, transcleral or endoscopic) had a success rate of 67% with 2.0 ± 1.0 treatments per eye. Trabeculectomy with mitomycin C (8 eyes) and trabeculotomy (8 eyes) had 25% and 0% success rates, respectively. Fifteen eyes that underwent glaucoma surgery obtained IOP control, and GDD with or without cycloablation accounted for 80% of the successes. Eyes that underwent PKP did not show increased rates of glaucoma, higher IOP, or a greater necessity for IOP-lowering surgery.

In Peters anomaly, PKP shows poor long-term success. In addition, >50% of eyes with Peters anomaly have secondary glaucoma that often requires multiple surgeries.

To report the outcomes of ipsilateral rotational autokeratoplasty (RAK) for nonprogressive paracentral corneal opacities in children <16 years of age.

Retrospective, consecutive, interventional case series.

Thirty-three eyes of 33 children aged <16 years undergoing RAK for nonprogressive paracentral scars.

Medical records were retrospectively reviewed for the primary etiology of corneal opacity, time of onset, duration of opacity, preoperative visual acuity, formula used for calculation of trephine size, size of the trephine used, and duration of follow-up. Any intraoperative and early and late postoperative complications were noted for all patients. Postoperative visual acuity and astigmatism were noted. Visual acuity was converted to logarithm of the minimum angle of resolution units for analysis.

Primary outcome was postoperative visual acuity. Graft clarity and complications were analyzed as secondary outcomes.

The mean age at surgery was 7.2±3.9 months. The mean follow-up duration was 27±37 months. The commonest etiology of corneal opacity was trauma (62.5%), followed by resolved microbial keratitis (21.9%). Postoperative visual acuity (1.25±0.84) was significantly better (P<0.001) than preoperative visual acuity (2.05±0.96). The mean astigmatism at last visit was 4.04±2.21 diopters. Postoperative visual acuity was better in older children (β = −0.01; P = 0.03) and had a shorter delay in presentation (β = 0.02; P = 0.05). At the last follow-up, the graft was clear in 27 cases (81.25%). The cumulative probability of graft survival was 85% at 2 years and 65% at 5 years. Complications included wound leak in 4 eyes, secondary glaucoma in 2 eyes, graft infiltrate and traumatic dehiscence in 1 eye each.

Rotational is a autokeratoplasty viable alternative surgical option to allogenic keratoplasty. Graft survival at 2 years seems to be better than allogenic keratoplasty. Younger age and delay in presentation contribute to poorer visual outcomes after surgery.

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

To report the outcomes of DSAEK surgery performed in pediatric patients.

Noncomparative interventional case series.

All pediatric patients (age up to 16 years) undergoing Descemet automated stripping endothelial keratoplasty (DSAEK) at our Institution since January 2008 have been enrolled in a prospective study. A standard DSAEK, involving delivery of an 8.5–9.5 mm graft by Busin glide, was performed under general anesthesia in 19 eyes of 11 pediatric patients (congenital hereditary endothelial dystrophy n = 13; congenital glaucoma n = 2; posterior polymorphous dystrophy n = 2, and failed penetrating keratoplasty n = 2). Slit-lamp examination, refraction and visual acuity as well as endothelial cell density were evaluated preoperatively as well as 1, 3, 6, 12, and 18 months postoperatively.

All surgical procedures were uneventful. Graft detachment occurred in 4 cases and was managed successfully with repeat air injection. All corneas cleared within a week from surgery. Follow-up was 3–18 months. At last follow-up examination, best-corrected visual acuity (BCVA) was better than 20/40 in 8 of the 13 cases of patients old enough to assess vision. A graft rejection episode was seen in 1 case within 3 months from surgery but was reverted with steroidal treatment. No graft failures were observed.

DSAEK is an appropriate surgical intervention for children with corneal endothelial failure. In contrast to penetrating keratoplasty (PK), DSAEK is performed under “closed system” conditions, thus minimizing intraoperative risks. Finally, healing is much faster than with PK and all sutures can be removed within 2–4 weeks from surgery, thus allowing fast visual recovery and prompt starting of amblyopia treatment.

To examine factors affecting penetrating corneal graft survival and visual outcomes in patients aged less than 20 years.

Large prospective, cohort study.

Records of 14 865 followed penetrating corneal grafts in 11 929 patients were searched to identify 765 grafts in 640 patients aged younger than 20 years of age at the time of graft.

Records submitted to the Australian Corneal Graft Registry by 381 ophthalmic surgeons and 253 follow-up practitioners from May 1985 to June 2009 were analyzed using Kaplan–Meier survival plots and Cox proportional hazards regression analysis.

Probability of corneal graft survival and Snellen acuity at the time of most recent follow-up and at defined intervals post-graft.

Infants (<5 years) exhibited poorer graft survival than children aged 5 to 12 years. Adolescents (13–19 years) exhibited better corneal graft survival than other age groups; 86% of grafts in adolescents were for keratoconus. Factors significantly affecting corneal graft survival in pediatric patients included indication for graft, graft inflammation, history of intraocular surgery, vascularization, rejection episodes, post-graft operative procedures, and refractive surgery. Fourteen percent of pediatric grafts failed, of which 65% failed within 2 years post-graft. Forty-four percent of failures were due to unknown causes (18) or irreversible rejection (30).

Corneal grafts for keratoconus in adolescents show excellent survival. Infants exhibit poor graft survival and visual outcomes, especially those undergoing transplantation for Peters' anomaly. Corneal graft survival and visual outcomes vary more by indication for graft than recipient age. The major reason for graft failure is irreversible rejection. Corneal transplantation improves overall bilateral vision in pediatric patients.

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

B. Cochener

The development of technologies for performing lamellar cuts of the cornea constitutes a major breakthrough in corneal grafting, since it can bypass the well-identified limits of penetrative keratoplasty such as intraocular pressure elevation and graft rejection with nonreversible edema, which are major but unpredictable complications of penetrative keratoplasty. A surgical procedure that could exchange only pathologic tissue layers might be able to eliminate all these adverse events and provide faster visual recovery with better visual performance. However, certain indications for penetrative graft will certainly remain, benefiting from the considerable progress in surgical technique with the advent of femtosecond laser and the the control of immunomodulation. This article develops arguments to answer the three following questions: Why should we replace penetrative keratoplasty? Why will this procedure survive? How can we improve it?

La mise au point de technologies capables de réaliser des découpes lamellaires de cornée représente une avancée majeure dans le domaine de la greffe de cornée, puisqu’elle ouvre la perspective d’un contournement de la kératoplastie transfixiante aux limites bien identifiées. Parmi celles-ci, le rejet, l’hypertonie oculaire et la décompensation œdémateuse représentent les complications majeures et volontiers imprévisibles de cette greffe complète de la cornée. La possibilité de ne changer que les couches tissulaires pathologiques pourrait outre éliminer ces suites indésirables, prétendre à une récupération visuelle plus rapide et à des performances optiques peut-être supérieures. Cependant persisteront très certainement des indications irréductibles à la greffe transfixiante, qui de son côté pourra fort heureusement bénéficier de progrès à la fois dans le domaine de sa chirurgie avec l’avènement de la kératoplastie transfixiante femtoseconde, ainsi que de sa vitalisation grâce à une maîtrise de l’immuno-modulation. Ce travail présente un développement des arguments capables d’aider à répondre à ces trois questions : pourquoi remplacer la greffe transfixiante, pourquoi survivra-t-elle et comment peut-on l’améliorer ?