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Post Keratoplasty Atopic Sclerokeratitis (PKAS) after Deep Anterior Lamellar Keratoplasty (DALK). Sharmina R Khan William H Ayliffe Mayday University Hospital, Croydon, London, UK. April 7-9, 2010 Boston, MA, USA.
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Post Keratoplasty Atopic Sclerokeratitis (PKAS) after Deep Anterior Lamellar Keratoplasty (DALK). Sharmina R Khan William H Ayliffe Mayday University Hospital, Croydon, London, UK. April 7-9, 2010Boston, MA, USA The authors have no financial interest in the subject matter of this presentation.
Introduction • PKAS is a severe (non-rejection) inflammation that infrequently occurs following keratoplasty. • A retrospective Japanese series found 6 eyes developed PKAS, of 29 with atopic dermatitis, of a total 247 eyes with keratoconus that underwent a keratoplasty procedure between May 2000 and December 2005 (1). • Clinical features: - Occurs in the early post operative period within the first few weeks. - Diffuse anterior scleritis. - Loosening of sutures, persistent epithelial defects and graft melting. • Differential diagnosis: • Acute epithelial rejection • Microbial keratitis (staphylococcal) • Tomita M, Shimmura S, Tsubota K, Shimazaki J. Postkeratoplasty Atopic Sclerokeratitis in Keratoconus Patients. Ophthalmology, 2008, May, 115 (5); 851-856. Sharmina R Khan, William H Ayliffe.
Introduction • Risk factors for PKAS: i) Atopic dermatitis/ Allergic eye disease (2) /Asthma (1) ii) Active blepharitis(1) iii) Corneal neovascularisation (1) iv) Elevated serum IgE(2) • Treatmentincludes early loose suture removal +/- resuturing, systemic Prednisolone +/- immunosuppressant. We describe our experience using poCyclosporin and poTacrolimus. • Prognosis can be excellent if treatment is timely. However, there is significant co-morbidity associated with the use of immunosuppressants. • Purpose of Presentation: We describe four cases of PKAS following DALK which has been described once before (3), all other reports have been following penetrating keratoplasty (PK). • Daniell MD, Dart JKG, Lightman S Use of cyclosporin in the treatment of steroid resistant post-keratoplasty atopic sclerokeratitis. Br J Ophthalmol 2001;85:91–92. • Lyons CJ, Dart JKG, Aclimandos WA, et al. Scleritis after keratoplasty in atopy. Ophthalmology 1990;97:729–33. Sharmina R Khan, William H Ayliffe.
Case 1: 34 year old woman • Keratoconus,severe eczema, atopic keratoconjunctivitis (AKC). • Right DALK (donor 8.25mm, host 8.0mm) 10/0 nylon continuous). • Preoperatively g. Fluoromethalone and g. Sodium Cromoglycate • 1 week later multiple suture related infiltrates developed. • poPrednisolone 30mg started and tapered rapidly • 3 weeks later loose sutures. • Inferiorly necrotic host cornea (arrow). • Graft re-sutured with interrupted 10/0 nylon. • poPrednisolone 40mg started and tapered over 6 months. • Loose sutures without inflammatory episodes were removed as required. • BCVA RE 6/9 Sharmina R Khan, William H Ayliffe.
Case 2: 14 year old boy • Keratoconus, atopic dermatitis. • Right DALK (donor 8.25mm donor, host 8.00mm, 10/0 nylon interrupted). • Pre-operatively g. Lodoxamide • 6 weeks post-op developed a graft epithelial defect followed by rapid stromal necrosis that did not respond to topical steroids and po Acyclovir. • 8 weeks later right tectonic DALK (lyophilised donor) interrupted 10/0 nylon with po Acyclovir prophylaxis. • 3/7 post-op developed loose sutures and non-necrotising anterior scleritis that persisted for 10/52. • poPrednisolone 30mg tapered over 6 months. • Repeat DALK due to early suture loosening. • Left DALK carried out under poPrednisolone cover and tapered over 6 months with an uneventful post-op course. • BCVA RE 6/9 • BCVA LE 6/9 Sharmina R Khan, William H Ayliffe.
Case 3: 29 year old man • Keratoconus, severe atopic dermatitis, AKC. • Left DALK (donor 8.0mm, host 8.25mm 10/0 continuous nylon). • Pre-operatively g. Lodoxamide TDS and g. Fluoromethalone TDS LE • 3 days post-op developed loose sutures, epithelial defect and non-necrotosing anterior scleritis. • 3 weeks later epithelial rejection line noted & poPrednisolone 60mg OD started • Inflammation continued resulting in host melting. • poCyclosporin 150mg BD started and tapered over 6 months. • Right DALK was carried out with poTacrolimus prophylaxis (commenced by dermatologist) post-op course was uneventful. • BCVA RE 6/6 BCVA LE 6/12 (stromal fibrosis 2⁰ recurrent shield ulcers). Sharmina R Khan, William H Ayliffe.
Case 4: 18 year old woman • Keratoconus, asthma, eczema, hayfever. • Right DALK (donor 8.0mm, host 8.25mm, 10/0 nylon continuous). • po Prednisolone 40mg OD and po Tacrolimus 2mg OD commenced 1/52 pre-op . • po Prednisolone tapered over 6/52 post op. • po Tacrolimus stopped 10/52 post op. • 1/12 later she had an exacerbation of eczema that required po Prednisolone and oral antibiotics. • Concomitantly developed sectoral anterior scleritis, loosening of sutures, deep corneal neovascularisation. • po Tacrolimus resumed and continuous suture removed. Sharmina R Khan, William H Ayliffe.
Case 4: 18 year old woman • 4/12 later developed epithelial rejection which responded to topical treatment. • Deep corneal interface vascularisation and fibrosis (arrows) progressed despite being on po Tacrolimus 2mg BD and po Prednisolone 7.5mg OD and g. Predsol 0.5% PF BD RE • Compliance with medication was a problem throughout. • BCVA RE 6/12 Sharmina R Khan, William H Ayliffe.
Discussion • Pre-operative management • Treat blepharitis and AKC as an atopic ocular surface is at increased risk of microbial (Staphylococcus aureus) keratitis. • Plan surgery when atopic disease is at its most quiescent, so that you are operating on a minimally inflamed eye. Sharmina R Khan, William H Ayliffe.
Discussion • Intra-operative management • Use interrupted sutures. • Post-operative management • In a DALK, PKAS may be less acutely destructive and more difficult to diagnose than in a PK. Sharmina R Khan, William H Ayliffe.
Conclusion • Early recognition is important as PKAS responds well to prompt suture management and systemic treatment. • We propose: i) Plan DALK instead of a PK in such high risk cases due to requirements for repeat grafting. ii) Use of systemic immunosuppressant as a prophylactic measure if PKAS has occurred in the first eye. Sharmina R Khan, William H Ayliffe.