Deep Anterior Lamellar Keratoplasty in Children

doi:10.1016/j.ajo.2012.09.029

American Journal of Ophthalmology

Volume 155, Issue 3, March 2013, Pages 570-574.e1

https://doi.org/10.1016/j.ajo.2012.09.029 Get rights and content

Purpose

To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) in children.

Design

Retrospective interventional case series.

Methods

setting: Institutional, L.V. Prasad Eye Institute, a tertiary care center in south India. study population and intervention: All children less than 16 years of age undergoing DALK from January 2003 to January 2011. main outcome measure: Visual outcome and complications.

Results

Twenty-six eyes of 26 children (13 male and 13 female) with a mean age of 7.82 ± 4.64 years underwent DALK for keratoconus (8), microbial keratitis (6), corneal scar (6), corneal keloid (3), chemical injury with limbal stem cell deficiency (2), and dermoid (1). Big bubble was achieved in 5 eyes, while manual dissection was done in 21. Follow-up ranged from 1 week to 7.3 years. Seventeen patients with a minimal follow-up of 6 months were evaluated for visual outcomes. Final vision varied from counting fingers to 20/20 (mean sphere 2.32 diopters, mean cylinder -2.5 diopters). Complications encountered were suture-related graft infiltrate (3), graft dehiscence (3), and Descemet membrane detachment (2).

Conclusions

DALK is a feasible option in children with stromal corneal pathology. It offers advantages in the form of lower risk of graft rejection. However, the risk of complications such as suture-related infections and graft dehiscence persists even in these cases.

Section snippets

Methods

After Institutional Review Board approval was obtained from L.V. Prasad Eye Institute, Hyderabad Eye Research Foundation, the medical and surgical records of 26 eyes of 26 children less than 16 years of age who underwent DALK at L.V. Prasad Eye Institute, Hyderabad, India from January 1, 2003 to January 1, 2011 were retrospectively analyzed. Data collected included patient demographics, clinical and surgical details, postoperative outcomes, and complications.

Results

The Supplemental Table (available at AJO.com) summarizes the patient demographics and surgical outcomes. The mean age of the cohort was 7.82 ± 4.64 years (range 6 months to 14 years); the cohort included 13 boys and 13 girls. Eleven patients were less than 5 years of age. The mean follow-up was 1.3 years (range 1 week to 7.3 years). Thirteen patients had surgery in the right eye and 13 in the left eye. The most common indication for surgery was keratoconus (8 patients), followed by nonherpetic

Discussion

Pediatric keratoplasty is a challenging surgery because of the anatomy and structure of a child’s eye.¹ The active immunologic system in a child makes the graft susceptible to rejection and eventually to failure.² Deep anterior lamellar keratoplasty may help in at least a subset of children with stromal pathology undergoing corneal transplantation by preventing endothelial rejection.

We performed DALK in a number of stromal pathologies. PK performed for keratoconus seems to enjoy a very high

References (24)

M. Vanathi et al.
Pediatric keratoplasty
Surv Ophthalmol
(2009)
W.J. Reinhart et al.
Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the American Academy of Ophthalmology
Ophthalmology
(2011)
S.A. Harding et al.
Indications and outcomes of deep anterior lamellar keratoplasty in children
Ophthalmology
(2010)
S. Pramanik et al.
Extended long-term outcomes of penetrating keratoplasty for keratoconus
Ophthalmology
(2006)
R. Limaiem et al.
Pediatric penetrating keratoplasty: indications and outcomes
Transplant Proc
(2011)
K.H. Kim et al.
Comparison of refractive changes after deep anterior lamellar keratoplasty and penetrating keratoplasty for keratoconus
Jpn J Ophthalmol
(2011)
M.T. Lowe et al.
The outcome of corneal transplantation in infants, children, and adolescents
Ophthalmology
(2011)
A. Anshu et al.
Outcomes of therapeutic deep lamellar keratoplasty and penetrating keratoplasty for advanced infectious keratitis: a comparative study
Ophthalmology
(2009)
W.B. Lee et al.
Traumatic wound dehiscence after deep anterior lamellar keratoplasty
J Cataract Refract Surg
(2009)
M.K. Aasuri et al.
Penetrating keratoplasty in children
Cornea
(2000)

M. Claesson et al.

Ten-year follow-up of graft survival and visual outcome after penetrating keratoplasty in Sweden

Cornea

(2009)

L.B. Jensen et al.

Longterm follow-up of penetrating keratoplasty for keratoconus

Acta Ophthalmol

(2010)

Cited by (42)

Update on pediatric corneal diseases and keratoplasty
2022, Survey of Ophthalmology
Citation Excerpt :
Elbaz and coworkers89 reported stromal rejection in five eyes (9.8%), of which four eyes responded to topical steroids and one graft failed. No graft rejection was seen in the series reported by Ashar and coworkers.25 Elbaz and coworkers 89 reported a significantly lesser endothelial cell loss of 8.3% in pediatric DALK, (as compared to that of 18.1–27.3%48,258 in adults).
Managing pediatric corneal disorders is challenging as the prognosis of pediatric keratoplasty depends on several factors. Advancements in the genetic basis of congenital corneal diseases and investigations in congenital corneal conditions provide a better understanding of pediatric corneal conditions. Surgeons performing keratoplasty in children now have a choice of various techniques. Evolving surgical techniques of anterior lamellar and endothelial keratoplasties have expanded the management interventions in these pediatric corneal morbidity conditions; however, considerable concerns still exist in association with corneal transplantation in infants and children. Outcomes in pediatric keratoplasty depend upon the preoperative indications, the timing of surgical intervention, intraoperative and postoperative factors including the patient/care givers’ compliance. Factors such as low scleral rigidity, higher rate of graft failure, need for frequent examinations under anesthesia, and difficulty in optimal visual acuity assessment still remain a considerable challenge in pediatric scenarios. In children, deprivation amblyopia as a result of the corneal opacification can adversely affect visual development, causing dense amblyopia. Outcomes to surgical interventions for management of corneal opacification in children are further compromised by the preexisting amblyopia apart from the concerns of refractive outcome of the graft. Graft rejection, graft infection, amblyopia, and glaucoma continue to be serious concerns. In recent years both anterior and posterior lamellar keratoplasty techniques are being increasingly performed in pediatric eyes, which offer advantages in the form of lower risk of graft rejection. The timing of surgery, careful case selection, cautious intraoperative approach, and optimal postoperative management can improve the anatomical and functional outcome in difficult cases.
Penetrating Keratoplasty Versus Deep Anterior Lamellar Keratoplasty in Children and Adolescents With Keratoconus
2021, American Journal of Ophthalmology
Citation Excerpt :
In the current study, both procedures resulted in excellent and comparable graft survival rates, which were 95.6% and 98.2% at the postoperative year 5 in the PK and DALK groups, respectively. The graft survival rate in our study was on the higher end of the reported range of 75%-93% in similar studies,7,8,11,12,19 most likely because of the strict postoperative follow-up visits and the fact that 1 experienced anterior segment surgeon performed all the surgeries and followed up the patients. Our results demonstrate that both techniques resulted in a comparable postoperative BSCVA, refractive error, mean keratometry, and keratometric astigmatism.
To compare the outcomes of penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) for pediatric keratoconus.
Retrospective comparative interventional case series.
This study included consecutive pediatric keratoconus cases (≤18 years of age) who received PK (n=45) or DALK (n=54) in 2 different time periods. Postoperative best spectacle-corrected visual acuity (BSCVA), refraction, and complications were compared between the study groups.
The mean follow-up was 83.3±46.1 and 63.3±45.6 months in the PK and DALK groups, respectively (P = .10). Postoperatively, BSCVA was 0.20±0.19 logMAR in the PK group and 0.26±0.19 logMAR in the DALK group (P = .11), with a BSCVA of ≥20/40 in 91.1% and 83.3% of eyes, respectively (P = .25). Two groups were comparable regarding postoperative refractive outcomes. Graft epitheliopathy and suture-associated complications were more commonly encountered after DALK, which was attributable to the effect of low-quality grafts on the clinical outcomes of DALK. Ten PK eyes (22.2%) and 9 DALK eyes (16.7%) experienced at least 1 episode of graft rejection within 5 years of corneal transplantation (P = .49). Rejection was reversible in 93.1% and 100% of episodes in the PK and DALK groups, respectively (P = .63). At the postoperative year 5, 95.6% of grafts in the PK group and 98.2% in the DALK group remained clear (P = .45).
No significant difference was observed in the outcomes between PK and DALK in pediatric keratoconus. Low-quality donor tissues in DALK increased the incidence of graft epithelial problems and suture-related complications as compared to PK.
A rare case of corneal keloid occurred 30 years after pterygium surgery and 3 years after cataract surgery
2020, American Journal of Ophthalmology Case Reports
We report a case of corneal keloid occurring 30 years after pterygium surgery and 3 years after cataract surgery.
The case of a 72-year-old man was referred because of blurred vision and corneal opacity in the right eye. Pterygium surgery had been performed on the right eye 30 years earlier, and bilateral cataract surgery had been done uneventfully via a temporal corneal incision 3 years ago. Deterioration of vision occurred in the right eye from 2 years ago. At the initial visit, his best corrected visual acuity (BCVA) was 20/2000 on the right. A white nodule that was well demarcated from the underlying stroma was seen on the right cornea. The nodule was excised by superficial keratectomy, with BCVA being 180/200 at 1 week after surgery. Pathological examination of the resected specimen revealed proliferation of fibroblasts and haphazard arrangement of collagen bundles, leading to a diagnosis of corneal keloid. Keloid-like lesion was also later noted in temporal corneal incision site of cataract surgery.
This rare case of corneal keloid occurred as a late complication of pterygium surgery.
Keratoplasty in infancy: how early is early?
2020, Journal of AAPOS
Anterior lamellar keratoplasty for the management of a central dermoid tumour in a baby
2020, Archivos de la Sociedad Espanola de Oftalmologia
Bebé de 3 meses de edad al que traen por presencia desde el nacimiento de una lesión blanquecina sobre la córnea del ojo derecho. Debido a las características clínicas y ultrasónicas de la lesión, se realizó una queratoplastia lamelar anterior manual. La anatomía patológica demostró la presencia de un coristoma epibulbar simple de grado II.
Los tumores dermoides suelen ser considerados benignos, pero pueden afectar de manera muy grave a la visión de un paciente pediátrico en función de su localización. La posibilidad de ambliopía en este tipo de casos obliga a procedimientos quirúrgicos con relativa urgencia. En los casos de afectación del eje visual sin implicaciones intraoculares la técnica de elección es la queratoplastia lamelar anterior.
A 3-month-old baby presented with a whitish lesion over the right cornea since birth. Due to the clinical and ultrasonic characteristics of the lesion, a manual anterior lamellar keratoplasty was performed. Histopathological examination showed it to be a simple grade II epibulbar choristoma.
Although dermoid tumours are usually considered as benign, some of them, depending on their location, can seriously affect the vision of a paediatric patient. Due to the high probability of amblyopia in these cases, a surgical procedure is mandatory. Anterior lamellar keratoplasty is recommended when the visual axis is compromised without intraocular implications.
Lamellar keratoplasty in children
2020, Survey of Ophthalmology
Citation Excerpt :
While early postoperative complications include DM detachment and double anterior chamber (AC), late complications include graft failure, rejection, and dehiscence. Ashar and coworkers and Arora and coworkers reported 7.6% (2/26) and 0.05% (1/20) cases of DM detachment in their series, respectively.5,7 Most of the DM detachments were related to intraoperative DM perforations and were managed conservatively or with the use of intracameral air/perfluoropropane (C3F8) gas injection, sometimes repeatedly, in the immediate postoperative phase.7,73
Lamellar keratoplasty procedures have gained momentum in the field of corneal transplantation because of their inherent advantages over full-thickness penetrating keratoplasty. While penetrating keratoplasty is an open sky procedure fraught with sight-threatening intraoperative and postoperative complications, lamellar keratoplasties are relatively closed-system procedures that involve selective removal and replacement of diseased corneal layers and are free from these complications. Anterior lamellar procedures involve partial or lamellar replacement of anterior stroma and reduce the risk of graft rejection, retain structural integrity, and require less stringent donor criteria. Posterior lamellar procedures involve removal of the affected endothelium in eyes with relatively unaffected stroma. These procedures are associated with improved safety profile, accelerated wound healing, structurally stronger globe, and minimal astigmatism, thereby producing faster visual rehabilitation and timely initiation of amblyopia therapy in children. Although the use of lamellar grafts is increasing in adults, their relatively slower adoption in pediatric population is attributable to the steep learning curve and lack of long-term follow-up data. We describe the challenges associated with these procedures and their outcomes in pediatric eyes.

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Original articleDeep Anterior Lamellar Keratoplasty in Children

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Surv Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Transplant Proc

Jpn J Ophthalmol

Ophthalmology

Ophthalmology

J Cataract Refract Surg

Penetrating keratoplasty in children

Cornea

Ten-year follow-up of graft survival and visual outcome after penetrating keratoplasty in Sweden

Cornea

Longterm follow-up of penetrating keratoplasty for keratoconus

Acta Ophthalmol

Original article
Deep Anterior Lamellar Keratoplasty in Children