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Pediatric Keratoplasty Presented by: Dr. Mohammad Abdullah Bawtag VitreoRetinal Consultant • Sana’a University • 2022
1824 Reisinger – First animal graft and coined the term “keratoplasty” • 1831 Dieffenbach proposes partial-thickness keratoplasty (LKP, extraocular procedure) • 1846 First use of general anesthesia – ether, at the Massachusetts General Hospital, Boston, MA • 1878 Arthur von Hippel, invented circular cutting trephine, blades of different diameters, a key for winding up the watch mechanism • 1888 Arthur von Hippel, first successful LKP in man • 1908 Plange – First human lamellar autograft (clear cornea from blind eye to opposite, scarred eye of the same patient). Graft remained clear for 5 years. • 1912 Magitot – Use of human cornea previously preserved in an antiseptic fluid for corneal transplantation.
In 1905 The first cornea transplant was performed by Eduard Zirm. • in 1955 Tudor Thomas ,conceived the idea of a donor system for corneal grafts and an eye bank was established in East Grinstead . • Real progress in past 40 years- KPro design, material, prevention and management of complications • Widespread use limited by early and late complications • The Dohlman or Boston Keratoprosthesis is the most popular now
keratoplasty Corneal Transplantation Corneal Grafting Keratoprosthesis
The cornea: is the transparent front part of the eye that covers the iris, pupil and anterior chamber.
Keratoplasty is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue (the graft). • When the entire cornea is replaced it is known as Penetrating Keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty.
Keratoprosthesis: is a surgical procedure where a severely damaged or diseased cornea is replaced with an artificial cornea to restore useful vision or to make the eye comfortable in painful keratopathy
The graft is taken from a recently deceased individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient. • Donors can be of any age, as is shown in the case of Janis Babson, who donated her eyes after dying at the age of 10. • Corneal transplantation is performed when medicines, keratoconus conservative surgery and cross-linking can no longer heal the cornea. • This surgical procedure usually treats corneal blindness,[with success rates of at least 41% as of 2021.
1- With Associated Glaucoma • Congenital glaucoma • Peters’s anomaly • Other anterior segment dysgenesis • 2. Without glaucoma • Sclerocornea • Dermoid • Birth trauma • Metabolic disease • Keloid • Aniridia • Acquired non-Traumatic • Keratoconus • Infective keratitis with or without perforation • Post infective corneal/ Corneo-iridic Scars • Keratomalacia Anterior segment photographs of eyes where congenital corneal opacity spontaneously regressed. a, b The right eye of a female patient with Peters anomaly at 25 days (a) and 15 months of age (b). c, d The left eye of a male patient with Peters anomaly at 22 days (c) and 6 months of age (d). e, f The left eye of a male patient with Peters anomaly
Types: • Based on Location • Central • Peripheral—Circular, oval, crescentic, annular, semilunar, rectangular or strip graft • Total—central and peripheral • Corneoscleral • Based on Stem-cell Transplantation • Non-stem cell KP • KP with stem cell transplantation (SCT)
Types of keratoplasty • Based on the thickness of the cornea transplanted, keratoplasty can be divided as: • Penetrating keratoplasty- involved full thickness of the cornea. • Lamellar keratoplasty- involves a transplantation of a part. • Anterior lamellar : SALK, MALK, DALK, TALK • Posterior lamellar : DLEK, DMEK, DSAEK
Dry Eye • Blepharitis • Ectropion • Entropion • Recurrent ocular infection • Melting cornea • Herpetic infection • Uveitis • Uncontrolled Glaucoma
Sever Ocular pathology • Technically difficult • Smaller eye • Elastic sclera • Shallow AC • Anterior displacement iris/ Lens • Young age • Poor cooperation • Hard to examine • Sudden rapid rejection The patients are different The Eyes are different The disease are different The surgery and anesthesia are different
Allograft rejection • Corneal scarring and neovascularization • Iridocorneal adhesions • Glaucoma • Cataract • Wound dehiscence • Amblyopia • Corneal steepening and high astigmatism • Graft infection and ulcer • Endophthalmitis • Persistent epithelial defect • RD • Phthisis
Contact lenses • Phototherapeutic keratectomy • Intrastromal corneal ring segments • Corneal collagen cross-linking
Pre operative Evaluation • Electroretinography (ERG) and Visually Evoked Response (VER) helpful in predicting the visual potential. • Pre operative Ultrasound examination to rule out presence of Retinal Detachment and other posterior segment abnormalities. • IOP should be maximally controlled before surgery
First 2 months • 2-3x / week • Frequent Postopretive EUAs • Early suture removal • Long term – slow taper of topical steroid over one year • Sedation p.r.n • No vaccination for one year • Co-management with pediatric ophthalmologist necessary • Optical correctio ASAP after suture removal
Prognosis • Best: • • Multiple Graft failure in a relatively non-inflamed eye with intact tear and blink mechanisms (following dystrophies, infections, etc) • • Aniridia and other limbal stem cell failure cases Intermediate: • • Chemical burns, HSV • Worst: • • Autoimmune diseases • • Mucous membrane pemphigoid • • Stevens-Johnson syndrome • Chronic uveitis
