Keratoplasty associated complications
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Transcript of Keratoplasty associated complications
Keratoplasty associated complicationsDR. KARAN BHATIAFELLOW CORNEA, PHACOEMULSIFICATION AND REFRACTIVE SURGERYMM JOSHI EYE INSTITUTE, HUBLI, KARNATAKA, INDIA
Introduction The history of "tissue transplantation" starts from Adam and Eve in Eden. Throughout history, however, the eye, as the avenue to the Sun God, has symbolized virtue and wisdom, with blindness as a penalty for impiety and the stigma of sexual shame. Blind people were generally regarded as social outcasts, for whom treatment of any sort represented a tampering with God's proper judgment. In myths and folklore, although occasionally the damaged eye was replaced by the fresh one, the eye is more usually replaced by its symbolic equivalent of wisdom or second sight.
DefinitionCorneal transplantation or grafting
is an operation in which abnormal corneal host tissue
is replaced by healthy donor cornea
Post-operative complicationsEARLY
◦ Shallow AC & Wound Leak◦ Iris Incarceration◦ Wound Dehiscence◦ Suture-Related Problems◦ DMD◦ Epithelial Defects◦ Filamentary Keratitis◦ Primary Graft Failure◦ Graft Rejection◦ Hyphema◦ High IOP & Pupillary Block Glaucoma◦ Low IOP◦ HSV Keratitis◦ Microbial Keratitis◦ Endophthalmitis
LATE (MONTHS, YEARS)
◦ Graft Rejection◦ Infectious Crystalline Keratopathy◦ Urretz-Zavalia Syndrome◦ Corneal Membranes◦ Hurricane (Whorl) Keratopathy◦ Cataract◦ Astigmatism◦ Glaucoma◦ Recurrence of Original Recipient disorder◦ Disease transmission from Donor Cornea◦ VR Problems
◦ RD◦ Macular edema
Early Post Operative ComplicationsVARY FROM MINOR TO TRUE OPHTHALMIC EMERGENCIES LOSS OF EYEMETICULOUS FOLLOW UP, EARLY DIAGNOSIS, TIMELY INTERVENTION MANDATORY
Shallow AC & Wound Leak• Shallow AC with Low IOP on POD1 Wound Leak
• IOP – normal/high – in some eyes
• Siedel’s test
• Prolonged Shallow ACSecondary glaucomaSignificant endothelial loss
• Causes Broken, Loose or misplaced sutureSuture track leak full thickness sutureSuture through thin or necrotic tissueExcessive gap between suturesUnequal thickness of graft and host
Shallow AC & Wound Leak – Prevention & ManagementAnterior Chamber
Flat
Wound suture tract leak or iris prolapse
Surgical Repair (immediately)
Formed
Wound Leak +
Pressure Bandage or BCL, Acetzolamide
If wound does not seal in 24 hours
Resuture
Interrupted sutures – replace loose/broken sutures Place additional suture in place of leak Continuous suture – loosen tight area and tighten area of
leak (redistributes tension) Suture tract leak – usually close spontaneously/ additional
mattress suture applied perpendicularly Corneal gluing & Bandage – for leak through necrotic tissue
Iris Incarceration• Causes
Collapse of AC/wound leakInflamed eyes/ Swollen & Flaccid Iris (preop)Poorly placed sutures
• Closes AC angle at site incarceration GlaucomaGraft failure
• Large adhesions at host-graft junction localized graft edema vascularization
Wound Dehiscence• Can occur immediately/several years later
• CausesTraumaInfectious KeratitisSuture FailureSpontaneous wound separation
• Resuture immediately
Suture Related ProblemsExposed
knotBroken suture
Tight suture
Loose suture
Unraveled suture knot
Suture abscesses Immune infiltrates
Vascularization
FB SensationGPCVascularizationNidus for infection
Persistent epithelial defects
Nidus for infection
ExposedFails to epithelize
Can loosen, become exposed or act as nidus
Poor prognostic factor for graftsCan lead to –• wound dehiscence• graft failure secondary
to infection• corneal scarring• endophthalmitis
Immunological reaction to suture material/ talc from surgical gloves
Hypersensitivity reaction to Staph albus (colonizes lid margins)
Rotation/ Replace with knot burried
Remove Replace Remove Debride suture roof, Suture & send for microbiological examBroad spectrum antibiotics
Topical steroids+ ciclosporin A
Immune suture infiltrates Infectious suture infiltrates
Multiple/small SolitaryOnly on host side Can occur on host/ graft sideNot associated with epithelial defect Epithelial defect common
Broken Suture
Tight Suture
Suture Infiltrates Suture induces Vascularization
Protruding suture with vascularization
Papillary hyperplasia
Descemet Membrane Detachment• Intracameral Air or C3F8/SF6 or viscoelastic
• Transcorneal Suturing
• Corneal Transplantation
Epithelial Defects• Re-epithelialization and maintenance of intact epithelium essential for post-op wound healing & Survival of graft
• Persistent >2-4 days without progress or healing
• Average time for complete epithelization – 4-6 days
Epithelial defects (contd) – Risk Factors
Ocular Surface Disorders
• Lid abnormalities – ectropion, entropion, lagophthalmos
• Infection & Inflammation – HSV
• Iatrogenic – tight sutures, dryness, poor apposition of graft-host junction
• Epitheliotoxic drugs – gentamicin, timolol, ciprofloxacin, prednisolone, dorzolamide, NSAIDs
•Damaged donor epithelium
•Basement membrane disorders
•Intrinsic epithelial disorder – Stem cell deficiency secondary to thermal/ chemical burns, SJS, Ocular cicatrical pemphigoid
•Trauma
•Poor nutrition – Vitamin A deficiency, PEM
•Metalbolic diseases – DM (both in donor and host)
Epithelial defects (contd) – Management• Prevent and Treat Risk Factors
• Adequate lid closure
• Prevent Corneal Exposure
• BCL
•Temporary Tarsorrhaphy
• Choramphenicol/ Panthogel
• Autologous Serum
• AMT
• HSV – Oral Acyclovir 300 mg BD
Filamentary Keratitis Reported Incidence of 27% in one case series*
*Rotkis WM et al. Filamentary Keratitis following penetrating keratoplasty. Ophthalmology. 1982;89:946-9.
Primary Graft Failure• Gross Corneal Edema in Graft with large broad folds immediately after keratoplasty
•Usually develops in POD1
• Not followed by a period of clear cornea
•Incidence <5% *
• Faulty donor tissue – results in irreversible graft edema in immediate post-op period
• Factors –Prolonged death-enucleation timePoor donor endothelial countAphakic and pseudophakic donorElderly donor Inadequate preservationSurgical traumaHSV infection
* Wilhelmus KR et al. Primary corneal graft failure. A national reporting system. Medical advisory board of Eye Bank Association of America. Arch Ophthalmol 1995;113:1497-502
Primary Graft Failure (contd)• Unresponsive to hypertonic saline/ steroids
•Proper donor selection
•Prolonged death to enucleation time – MK media can preserve donor tissue only up to 2 hours
•Early surgery & Minimal surgical trauma
•Observe for 3-4 weeks. No improvement Repeat Penetrating Keratoplasty
Graft Rejection•Graft clear for atleast 2 weeks graft edema + inflammatory signs
Hyphema•Incidence increases with intraoperative manipulations like extensive synechiolysis, iridoplasty or iridotomy
•Clears spontaneously without treatment
•IOP high – then treat aggressively
•Β-Blockers + Briminodine/Acetazolamide
•Prolonged persistence – Clot irrigation and aspiration
High IOP & Pupillary Block Glaucoma
Due to –
•Residual viscoelastics in AC
•Uveitis
•Hyphema
•Crowding of AC angle
•Pupillary block
•Forward movement of lens iris diaphragm
FLAT/ Shallow AC with closely secured wound (Siedel’s Negative) Pupillary block/ Choroidal detachment
Choroidal detachment – low IOP
Low IOP Causes –
•Wound Leak
•Iridocyclitis: Ciliary shock
•Cyclodialysis
•Choroidal detachment
•Retinal Detachment
HSV Keratitis•HSV Keratitis can incite graft rejection and vice versa
• Patterns –DendriticGeographicStromal – graft edema, KPs – difficult to distinguish from graft
rejection
However, HSV – focal involvement, propensity to occur at graft host junction
Absence of Khadadoust Line
•Topical Acyclovir 5 times/day x 2 weeks Post-op
•Oral Acyclovir 400 mg BD/ Valacyclovir 500 mg BD x 1 year
Microbial Keratitis• Incidence higher in developing countries• ½ occur within 1st 6 months of surgery• Either infection within graft/ along suture tracts at
graft host junction
Inflammatory Reaction
Initiation of Graft Rejection
Graft Failure Graft MeltingEndophthalmitis
• Corneal scrapings – Gram’s stain/KOH/C & S• Therapy modified based on lab report• Initial therapy – Fluoroquinolone or combination of
Cefazolin 5% and Tobramycin 1.3%
Endophthalmitis• Vitreous Tap
•Intensive topical, intravitreal and systemic antibiotics
Late Post-operativeMONTHS, YEARS
Graft Rejection
Ciliary Injection in pre-rejection Elevated epithelial line in epithelial rejection
Krachmer Spots in Stromal Rejection Endothelial Rejection (Khoudadoust line)
Infectious Crystalline Keratopathy•Chronic, progressive corneal infection
•Anterior lamella of graft involved
•No clinically evident stromal inflammation
•Crystalline branching opacities in anterior & mid stroma
Urrets-Zavalia Syndrome•Permanent fixed dilated pupil after penetrating keratoplasty/DALK in patients with keratoconus
•Iris atrophy
•Secondary glaucoma
•Mydriasis unresponsive to miotics
•Unknown etiology (severe iris ischaemia – possible mechanism)
•Management –• Reduce IOP• Avoid Atropine pre-operatively• Peripherally painted Contact Lens for photophobia, glare
Corneal Membranes Epithelial ingrowth (conjunctival/corneal) – through gap at host-graft junction
Fibrous ingrowth (retrocorneal membrane) – gray/white fibrous membranes between DM and endothelium
Hurrican (whorl)/ Vortex Keratopathy
Cataract•Incidence varies from 25-80% *
•Due to –Poor surgical techniqueAltered lens metabolismToxic – corticosteroids, anticholinesterase
*Rathi VM et al. Cataract formation after Penetraing keratoplasty. J Cataract Refract Surg. 1997;23:562-64
Astigmatism•Average – 4-5 D
•Higher in eyes with – Scarring due to corneal ulcerKeratoconusEccentric graftMal-aligned graftFaulty suturing techniques
Improper placement of second suture Unequal depth Non-radial sutures Tight sutures Unequal distribution of tension in continuous suture
Surgical Caveats to minimize Astigmatism
•Central and sharp trephination
•Use of a sharp trephine
•Symmetric suture placement (especially 2nd suture)
•Avoid tight suture placement
•Suture adjustment (for continuous suture) or selective suture removal (for interrupted sutures)
Glaucoma•Due to PAS and epithelial downgrowth
•2 unique mechanisms –Collapse of trabecular meshworkCompression of AC angle
•Larger Donor Grafts – associated with deeper AC lower incidence of post-op progressive angle closure and lower post-op IOPs
•Avoid Dorzolamide
•Laser Trabeculoplasty
•Trabeculectomy with MMC GDD Surgery
Recurrence of Original Recipient Disorder•Due to migration of recipient keratocytes into graft stroma
•Occurs frequently in –Granular – 100% at 4 years*Macular – 5.2%**Lattice – 48%***Reiss Buckler’s dystrophyCentral crystalline dystrophyPosterior Polymorphous dystrophy
•Repeat graft
•Superficial keratectomy/ Excimer laser Phototherapeutic keratectomy – for superficial lesions
*Lyon CJ et al. Granular corneal dystrophy. Visual results and pattern of recurrence after lamellar or penetrating keratoplasty. Ophthalomology 1994;101:1812-17** S. Al-Swailem A et al. Penetrating keratoplasty for macular corneal dystrophy. Ophthalmology. 112(2):220-24*** Meisler DM et al. Recurrence of clinical signs of lattice corneal dystrophy (type I) in corneal transplants. Am J Ophthalmol. 1984;97:210-14
Vitreoretinal problems Retinal Detachment
•Rare
•Incidence increases with complicated procedure, especially after vitreous manipulation
Macular Edema
•Common cause of non improvement of vision despite clear graft
•Predispositions –Aphakic bullous keratopathyPseudophakic bullous keratopathyTraumaAny previous intraocular surgery
Thankyou