BackgroundPenetrating keratoplasty (PK) ranks among the oldest and most common kinds of human tissue transplantation. Based on the hypothesis that reported indications for PK significantly vary between global regions and over time, the present systematic review aimed to provide a thorough overview o

Changing Indications in Penetrating Keratoplasty: A Systematic Review of 34 Years of Global Reporting

BACKGROUND The success of penetrating keratoplasty (PKP) after penetrating eye injuries is often worse than in keratoplasty with Fuchs' endothelial dystrophy. However, comparable investigations are rare. Therefore, we have retrospectively analyzed the results and complication rates of PKPs in patients who experienced penetrating eye injuries. PATIENTS AND METHODS Between 1990 and 1997 forty-four patients who received a corneal transplant at Kiel University Eye Hospital after penetrating eye injury (study group S) were analyzed. 29 patients were re-examined (visual acuity testing, slit lamp microscopy, applanation tonometry, stereo testing, corneal TMS topography, keratometry, endothelial microscopy, perimetry, indirect retinoscopy, testing of the retinal visual acuity and probatory contact lens fitting). Postoperative follow-up ranged between 1 and 6 years (median 3 years). The results were compared to a group of corneal grafts performed in patients with Fuchs' endothelial dystrophy (K, n = 18 patients, 25 eyes, median follow-up 2.8 years). RESULTS 38males and 6 women had had a bilateral visual acuity of 0.8 or better before the accident, except for three cases. At the time of eye injury the patients' age ranged from 4 to 76 years. The eye trauma was caused by splinters of metal (45 %), glass (20 %), wood (16 %) or stone (11 %). In 73 % of the cases the injury was confined to the anterior segment of the eye (S1). The posterior part of the eye was involved in 27 % (S2). BCVA of S before keratoplasty (KP) was 1/15 on average (K 0.2), at least one year after KP 0.25 (K 0.4); post KP S1 was better than S2 (p = 0.0234), and K better than S (p = 0.0009). In group S 29 patients received a graft at random because of a central corneal scar, 14 patients received an HLA-typed graft with 2.3 mismatches on average. 93 % of the grafts (41 patients) were clear at the last examination, 8 patients showed rejection episodes, half of them were reversible. 5 patients received a second graft because of an irreversible rejection or endothelial decompensation. BCVA improved by at least one line in 84 % in S (K 92 %). BCVA was unchanged after KP in 6.8 % (K 8 %). In 9.1 % of S BCVA after KP was worse (K 0 %). 32 out of 44 patients had a BCVA of 0.1 or better after the last check-up, 13 out of 44 patients presented with a BCVA of 0.5 or better (K40 %). 15 out of 29 patients separately tested showed stereopsis compared to 8 preoperatively in S. In 48 % of the patients studied stereovision could not be restored. 82 % of the patients suffered from topographical irregular astigmatism in S, the superficial geometry of recipient's cornea seems relevant for astigmatism of the graft. Frequent postsurgical complications consisted of secondary glaucoma (S 27 %, K 4 %), immunological rejections (S 18 %, K 0 %), and amblyopia (S 14 %, K 0 %). CONCLUSION Compared to patients with Fuchs' dystrophy the results of grafting after eye injuries are significantly worse. This relates to BCVA, astigmatism, frequency of secondary glaucoma and graft rejection.

Prognose von Korneatransplantationen nach Bulbusperforation

12 patients developed pseudophakic bullous keratopathy 2 to 7 years following i.c. cataract-extraction with implantation of 4-loop iris clip lenses necessitating perforating keratoplasty. To study the pathogenesis of pseudophakic bullous keratopathy the corneal endothelium of the excised button was investigated light-microscopically after vital staining of the endothelium. Additionally the surface of the explanted intraocular lenses were examined by the method of Wolter. The result is a central cell density of the excised corneal buttons between 179 and 867 cells/mm2. Large cell-free areas were always found indicating that a disturbance of the endothelial barrier function is the major reason for corneal decompensation. A relation between inflammatory cell deposits on the IOL-surfaces and the endothelial decompensation was not apparent. As the main reason for endothelial decompensation a chronical mechanically induced endothelial cell loss is supposed leading to disturbances of the endothelial barrier function. To prevent a repeated corneal decompensation it is recommended to remove iris-clip-lenses during the procedure of perforating keratoplasty.

Pathologie des hornhaut-endothels bei der bullosen keratopathie nach iris-cliplinsen-implantation

Von 1980 bis 1987 gingen 118 Hornhautexzisate von Augen, bei denen nach Kunstlinsenimplantation eine Hornhaut-Endothel-Dekompensation eine perforierende Kerato-plastik erforderlich gemacht hatte, in unserem ophthalmopathologischen Labor ein. Im Rahmen unserer Studie wurden diese Exzisate histologisch anhand von insgesamt 46 zuvor definierten, quantitativen und semiquantitativen Kriterien nachuntersucht und statistisch ausgewertet.

Histologie der Hornhaut-Endothel-Epithel-Dekompensation nach Kunstlinsenimplantation

Von September 1980 bis Februar 1992 wurden an unserer Klinik insgesamt 2100 Keratoplastiken durchgefuhrt. Bei 152 Augen von 145 Patienten waren perforierende Keratoplastiken wegen Hornhaut-Endothel-Epithel-Dekompensation (HEED) nach uberwiegend extern implantierten Kunstlinsen erforderlich. Mittels prospektiver Erfassung und statistischer Auswertung der Patientendaten untersuchten wir Verlauf, Prognose und mogliche visus- und komplikationsbeeinflussende Faktoren. Insbesonders interessierten uns hierbei die Ergebnisse der 46 Augen, bei denen simultan nahtfixierte Hinterkammerlinsen (HKL) implantiert wurden. Die Nachbeobachtungszeit betrug durchschnittlich 15 Monate. Bei 77 der 152 Augen waren ursprunglich irisfixierte Kunstlinsen (IFL), bei 44 kammerwinkelgestutzte Vorderkammerlinsen (VKL) und bei 31 Augen nach extra-kapsularer Kataraktextraktion (ECCE) HKL implantiert worden. 8 der Kunstlinsen waren bereits zuvor entfernt worden, 39 wurden intraoperativ belassen, 61 entfernt und 52 ausgetauscht. Bei 46 Augen mit defektem Iris-Linsen-Diaphragma wurde nach IFL-oder VKL-Entfernung eine HKL sekundar implantiert und retropupillar entweder mittels zweier Irisnahte (32 Augen) oder mittels transskleraler Naht (14 Augen) fixiert. Bei 91% der Augen konnte eine Visus-verbesserung erzielt werden, der erreichte Visus war jedoch haufig durch persistierende zystoide Makulopathien beeintrachtigt. HEED nach extrakapsularer Kataraktextraktion mit HKL hatten eine deutlich bessere Prognose (signifikant besserer Visus, signifikant seltenere zystoide Makulopathien) als solche nach IFL oder VKL. Die Augen mit sekundaren nahtfixierten HKL zeigten im Vergleich zu den nach einer Kunstlinsenexplantation aphaken Augen ahnliche postoperative Verlaufe, keine erhohte Komplikationsrate und vergleichbare korrigierte postoperative Visusergebnisse.

Keratoplastik wegen pseudophaker Hornhaut-Endothel-Epithel-Dekompensation. Bericht über 152 Augen

During the period from 1980 until the beginning of 1986, 1,219 corneal buttons removed in the course of penetrating keratoplasty were histologically examined. In 16.5% (201 cases) a re-keratoplasty was necessary. Indications for a primary corneal transplant (n = 1,018) were keratitis-induced corneal changes (35.0%), dystrophies (30.5%), surgical traumas (17.2%), nonsurgical traumas (11.4%), congenital corneal clouding (3.1%) and degenerations (2.8%). Over the six-and-a-half-year period the incidence of pseudophakic bullous keratopathy was 6.9%, with an increase from 1.6% in 1980 to 12.4% in 1986. Besides an unspecific endothelial cell atrophy, fibroblast-like cell structures, possible macrophages, were found in some specimens by histologic examination on corneal buttons as well as on explanted intraocular lenses.

Die perforierende Keratoplastik - Indikationen unter besonderer Berücksichtigung der Kunstlinsenkeratopathie

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Die perforierende Keratoplastik - Indikationen unter besonderer Berücksichtigung der Kunstlinsenkeratopathie