Download stromal rejection episode after deep anterior lamellar keratoplasty

Acta Ophthalmologica 2015, Vol.41(1)
ISSN 1452-3868
Originalan rad
UDK: 611.841+617.7-089+615.461
STROMAL REJECTION EPISODE AFTER DEEP ANTERIOR LAMELLAR
KERATOPLASTY (DALK)
Ljubiša Nikolić*, Vesna Jovanović**, Slađana Delević*
* Special Eye Hospital Oculus
** Faculty of Dentistry University of Belgrade, Ophthalmology Clinic, “Prof. dr
Ivan Stanković”, KBC “Zvezdara”
Purpose: To report an uncommon complication of the deep anterior lamellar
keratoplasty in a patient with keratoconus.
Methods: Deep anterior lamellar predescemetic keratoplasty was done in a
patient with advanced keratoconus. Orbscan was used for corneal topography and
thickness measurements. Rostock cornea module was used to measure the
endothelial cell count.
Results: Patient had a stromal rejection episode 14 months postoperatively.
After its reversal, the graft remained clear, but with only 1449+19 cells per mm2.
Conclusion: Although safer than a penetrating graft, the deep anterior lamellar
corneal transplantation is not devoid of complications. However, complications can
frequently be managed successfully by using medical therapy. The frequency of rejection
can probably be lessened by a timely suture removal. Acta Ophthalmologica
2015;41(1):18-22.
Key words: cornea, DALK; keratoconus; rejection
Introduction
Deep anterior lamellar keratoplasty (DALK)
has become an alternative to penetrating
keratoplasty (PK) in the treatment of
keratoconus (KC) (1). Although PK is easier to
perform and can yield superior visual results to
lamellar keratoplasty, the disadvantages of the
full-thickness graft include less intraoperative
safety, a weakness to blunt trauma at the edge
of the graft, an irregular astigmatism, and more
frequent rejection episodes followed by more
frequent graft failures (2). DALK permits
preservation of the healthy endothelium of a
young recipient, which makes late endothelial
failure less probable and excludes endothelial
rejection. However, the rejection of other
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corneal layers is still possible (3,4). In the past,
rejection of the epithelium and stroma in a
lamellar graft were believed to be so rare that
the authors used the word “exceptional” (5).
More recently, the rejection of these layers was
found to happen in 4.3%, 4.5%, and even
14.3% (6-8). Most of these grafts were saved
after topical corticosteroid therapy. Thus, it
seems worthwhile to address this issue again.
We report a case of stromal rejection after
DALK for keratoconus with epithelial edema
and small bullae formation at the time when all
donor epithelium was expected to be replaced
by the host epithelium, making an epithelial
rejection impossible, and present the
endothelial cell loss found after the rejection
reversal.
Acta Ophthalmologica 2015, 41(1)
Materials and methods
A 37-year-old Caucasian man with keratoconus
was reported for keratoplasty. He had a history
of eye rubbing and contact lens intolerance. He
had never experienced episodes of either
vernal conjunctivitis or herpes. Munson’s sign
was obvious in the right eye. Visual acuity of
his right eye was finger counting at four meters,
and could not be improved by any spectacle
lenses. In his left eye, a spectacle correction of
-2.75–1.50X100 gave a BCVA of 20/25. His left
eye presented as a forme fruste keratoconus.
On the slit-lamp examination, only a thin conical
cornea was observed, without any signs of the
corneal hydrops, guttae, keratic precipitates, a
flare in the anterior chamber or vernal conjunctivitis.
Axial length was 24.7mm and 24.2mm respectively.
Orbscan (Bausch and Lomb, Munich, Germany)
revealed a typical keratoconus in his right eye,
with a thin cornea (340 micrometers) paracentraly and centrally, and of a normal thickness
at the periphery (540 micrometers). (Figure 1)
Endothelial cell count was measured with the
Rostock Cornea Module (RCM) of Heidelberg
Retina Tomograph (HRT) (Heidelberg Engineering
GMBH, Dossenheim, Germany).
Descemet’s membrane and endothelium
were swept off from the donor cornea, which
had previously been kept for five days in
Optisol (Bausch and Lomb). An 8.50mm graft
was transplanted into an 8.25mm corneal bed
created by predescemetic dissection, and
sutured with 18 interrupted 10-0 nylon sutures.
Dexamethasone and gentamycin were injected
subconjunctivally at the end of surgery. Seventeen
sutures were taken off during the first three
months postoperatively. One deeply buried
suture was left at 10 o’clock. Dexamethasone
0.1% drops were tapered from six times to
once daily. Seventeen sutures were taken off
during the first three months postoperatively.
was clear. The graft was edematous and hazy,
but without vascularization, precipitates or
infiltrates. Epithelium was edematous, with
small bullae and erosions (Figure 3A). The
graft-host interface seemed inconspicuous.
Intraocular pressure was 14mm Hg. It took
three months to clear the graft with topical
Dexamethasone 0.1% eye-drops eight times
daily for a month and six times daily for two
months, and 5% sodium chloride ointment before
bedtime. After the treatment, intraocular pressure
was 17mmHg, but a posterior cortical cataract
was noted in the right eye only. BCVA
deteriorated to 20/60. Endothelial cell count
was 1449+SD 19 in the operated eye, and
2689+SD 19 in the intact eye. (Figure 3B) Five
months later, phacoemulsification and intraocular
lens implantation were done. The graft remained
clear, and the correction of -0.5-1.75X100 gave
BCVA of 20/25.
Figure 1.Stromal and epithelial edema of the graft,
14 months after DALK
Results
The graft remained clear during a 14
months follow-up. (Figure 2) At 12 months,
BCVA was 20/30 with the correction of -6.0–
1.0X110. Endothelial cell count, measured with
the Rostock Cornea Module (RCM) of Heidelberg
Retina Tomograph (HRT) (Heidelberg Engineering
GMBH, Dossenheim, Germany) was 2016+SD
19. Then, the patient appeared between two
monthly visits, complaining of a sudden visual
deterioration which had lasted for five days. At
the slit-lamp, the peripheral, recipient cornea
Figure 2. Clear lamellar graft after rejection reversal
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Acta Ophthalmologica 2015, 41(1)
Discussion
Figure 3A. Graft endothelium after rejection reversal
shows cell loss and polymegatism
Figure 3B. Normal endothelial cell count and
appearance before rejection episode
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Our patient was young, active, with a
history of eye rubbing and contact lens
intolerance. His low visual acuity could not be
corrected with spectacle lenses. His central
cornea was very thin and without signs of an
ongoing or past hydrops. The aim of surgery
was to achieve a useful visual acuity, normal
corneal thickness, optimal peripheral wound
strength, while preserving the healthy endothelium
and lessening the chances of rejection. Therefore,
it was decided to rule out penetrating keratoplasty,
intracorneal rings and collagen cross-linking,
and to perform DALK with the use of interrupted
sutures in order to stimulate healing at the edge
of the graft (9).
A sudden edema of the graft appeared 14
months after surgery. In the absence of any
diagnostic tests, it was diagnosed clinically as
rejection (3). Herpes was excluded as the
cause of the graft opacity because there had
not been a history of ocular or labial herpetic
infection, there were no obvious clinical signs of
the disease, and a short topical corticosteroid
treatment did not cause a progression of the
corneal disease. The inconspicuous graft-host
interface helped to rule out keratitis originating
from that site. Vascularization and infiltrates in
a graft, frequent but not necessary accompanying
signs of rejection (4,5), were missing in this
case. However, the retained interrupted suture
was suspected to be the immune reaction
trigger (10).
Our case presented with both epithelial and
stromal edema 14 months after the surgery,
and five days after the beginning of the
symptoms. The epithelial rejection would not be
possible at that time because of the prior
replacement of the donor epithelium by host
epithelium (10,11). On the other hand, the first
stromal rejection episode may happen even 41
months after DALK (4). Moreover, the epithelial
edema in our case looked as if being caused,
at least partially, by endothelial dysfunction.
Watson, Tuft and Dart have already discussed
this possibility, and have suggested inflammation
in the stroma, stromal cellular infiltrates, and
abnormalities in the endothelium of keratoconus
patients as possible causes of endothelial
decompensation (4). In our case, the 28% loss
of endothelial cells during the rejection episode
seemed to be one of the causes of the endothelial
decompensation which took three months to
clear, possibly by sliding of the host endothelial
cell in the presence of a therapeutically
suppressed immune reaction. It seems probable
Acta Ophthalmologica 2015, 41(1)
that this loss can be attributed to the inflammatory
immune reaction based on the difference
between pre- and post-rejection endothelial cell
counts, from the estimate of the long-term
endothelial loss after uncomplicated DALK to
be up to 13% (12-15), as well as from the
absence of contact lens wear, which proved to
be harmful to the endothelium in keratoconus
(16). The exactness of the method which we
used has been shown by a recent comparison
of the mean endothelial cell densities measured
with an endothelial microscope (EM) and with
RCM showing no significant differences, although
EM counts had a lower standard deviation (17).
In conclusion, we present a previously
uncommon complication of DALK: high endothelial
cell loss after a rejection episode. Its incidence
can probably be lowered by a timely suture
removal, while its reversal can be accomplished
by medical therapy.
References
1. Agarval R. Deep lamellar keratoplasty: an alternative
for penetrating keratoplasty (editorial). Br J
Ophthalmol 1997;81:178-9.
2. Benson WH, Goosey JD Lamellarke-ratoplasty. In:
Krachmer JH, Mannis MJ, Holland EJ (Eds).)
Cornea 2nd Edition; Volume 2, Elsevier Mosby,
Philadelphia 2005, pp 1685-93.
3. Al-Torbak A, Malak M, Teichmann K et al.
Presumed stromal graft rejection after deep
anterior lamellar keratoplasty. Cornea 2005;24:
241-3.
4. Watson SL, Tuft SJ, Dart JKG. Patterns of rejection
after deep lamellar keratoplasty. Ophthalmology
2006; 113:556-60.
5. Offret G, Pouliquen Y (1974) Les homogreffes de
la cornee. Masson etCie, Paris p 93.
6. Borderie VM, Werthel AL, Touzeau O et al.
Comparison of techniques used for removing the
recipient stroma in anterior lamellar keratoplasty.
Arch Ophthalmol 2008;126:31-7.
7. Chen W, Lin Y, Zhang X et al. Comparison of fresh
corneal tissue versus glycerin-cryopreserved corneal
tissue in deep anterior lamellar keratoplasty.
Invest Ophthalmol Vis Sci 2010; 51:775-81.
8. Feizi S, Javadi M, Jamali H et al. Deep anterior
lamellar keratoplasty in patients with keratoconus:
big-bubble technique. Cornea 2010: 29:177-182
9. Abdelkader A, Elewah EM, Kaufman HE. Confocal
micrscopy of corneal wounds healing after deep
10.
11.
12.
13.
14.
15.
16.
17.
lamellar keratoplasty in rabbits. Arch Ophthalmol
2010;128:75-80.
Dua HS, Jayaswal R, Said DG.Stitched up: full
thickness corneal grafts. Editorial. Br J Ophthalmol
2008;92:869-70.
Khodadoust AA, Silverstein AM. The survival and
rejection of epithelium in experimental corneal
transplants. Invest Ophthalmol 1969;8:169-79.
Tham VM, Abbot RI. Corneal graft rejection: recent
updates. Int Ophthalmol Clin 2002;42:105-13.
van Dooren BTH, Mulder PGH, Neuwendaal CP
et al. Endothelial cell density after deep anterior
lamellar keratoplasty (Melles technique). Am J
Ophthalmol 2004; 137:397-400.
Fontana L, Parente G, Tassinari G, etal.Clinical
outcomes after deep lamellar keratoplasty using
the big-bubble technique in patients with
keratoconus. Am J Ophthalmol 2007;143:117-24.
Sarnicola V, Toro P, Gentille D et al. Descemetic
DALK and predescemetic DALK: outcomes in 236
cases of keratoconus. Cornea 2010;29:53-9.
Edmonds CR, Wung SF, Pemberton B. Corneal
endothelial cell count in keratoconus patients after
contact lens wear. Eye Contact Lens 2004;30:54-8.
Rieth S, Engel F, Buehner E et al. Comparison of
data from the Rostock Cornea Module of the
Heidelberg Retina Tomograph, the Oculus
Pentacam, and the endothelial cell microscope.
Cornea 2010; 29:314-20.
EPIZODAO ODBACIVANJA STROME KALEMA POSLE DUBOKE
PREDNJE LAMELARNE KERATOPLASTIKE (DALK)
Ljubiša Nikolić*, Vesna Jovanović**, Slađana Delević*
*Specijalna očna bolnica Oculus
**Stomatološki fakultet Univerziteta u Beogradu, Klinika za očne bolesti “Prof.
dr Ivan Stanković”, KBC “Zvezdara”
Cilj: Prikaz neuobičajene komplikacije duboke prednje lamelarne keratoplastike
kod keratokonusa.
Metod: Pacijentu sa odmaklin keratokonuson urađena je duboka prednja
lamelarna keratoplastika u nivou neposredno iznad Descemetove membrane.
Kornealna topografija i debljina rožnjače određivane su Orbskenom. Broj endotelnih
ćelija rožnjače određivan je pomoću konreralnog modula Roštok.
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Acta Ophthalmologica 2015, 41(1)
Rezultati: Epizoda odbacivanja strome javila se 14 meseci posle operacije.
Pošto je reakcija zaustavljena, kalem je ponovo postao providan,ali sa samo
1449+19 ćelija na mm2.
Zaključak: Duboka prednja lamelarna keratoplastika je bezbednija od
perforativne, ali ni ova operacija nije bez komplikacija. Međutim, komplikacije se
često mogu zbrinuti medikamentnim lečenjem. Učestalost epizoda odbacivanja
verovatno može da se smanji pravovremenim uklanjanjem svih sutura. Acta
Ophthalmologica 2015;41(1):18-22.
Key words: DALK, keratokonus, odbacivanje
Kontakt: Prof. dr Ljubiša Nikolić,
Specijalna očna bolnica Oculus,
11000 Beograd, Bulevar Mihaila Pupina 10
E-mail:[email protected]
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