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- Paediatric keratoplasty
- endothelial keratoplasty
- Descemet's stripping endothelial keratoplasty
- cornea
- dystrophy
- eye (tissue) banking
- ocular surface
- optics and refraction
- infection
- immunology
- imaging
- microbiology
- inflammation
Introduction
A significant proportion of paediatric keratoplasties are performed for endothelial dysfunction due to failed graft, congenital hereditary endothelial dystrophy1 and pseudophakic corneal oedema. Descemet's stripping endothelial keratoplasty (DSEK) is an evolving procedure for isolated endothelial dysfunction with encouraging results in adults. The application and outcome of this procedure in the paediatric population has not been well studied with few reports being published so far.2–5
This study reports the indications, surgical technique and early outcomes of DSEK in children <14 years of age.
Methods
All children who underwent DSEK at our centre between January 2008 and January 2010 were included. Under general anaesthesia, an appropriate sized superior or temporal fornix based conjunctival flap was reflected and a 4–5 mm long, self-sealing scleral tunnel was made. The Descemet's membrane was scored using a reverse Sinskey hook and then stripped (except in cases of failed grafts). An anterior chamber maintainer was used to ensure maintenance of anterior chamber depth throughout the surgery. Where necessary, Chandelier illumination or trypan blue staining was used to improve visualisation of the Descemet membrane.
The donor lenticule was prepared by dissection of a donor tissue using the Moria anterior lamellar keratoplasty system (Moria, Pennsylvania, USA) or using a manual technique. The donor graft was punched to appropriate size and inserted into the anterior chamber over a sheet's glide using a push in technique using bent 26-gauge hypodermic needle. A complete air fill was maintained in all cases at the end of the surgery. Peripheral iridotomy was made to prevent pupillary block.
Postoperatively the children were maintained on tapering doses of topical prednisolone acetate 1% drops. The children were followed up weekly for the first 2 weeks, then fortnightly for 1 month and monthly later on. Patients with a minimum follow-up of 6 months were included for the analysis of visual acuity and graft outcome.
Results
Sixteen eyes of 16 children underwent DSEK. The mean age was 8.06±3.95 years (1–14 years). The preoperative and postoperative clinical data are summarised in table 1.
Clear grafts were obtained in 15/16 (93.75%) cases (figure 1). One patient had a primary graft failure. The final visual acuity in 11 cases who had 6 months follow-up ranged from 20/50 to 20/260 (table 1). The mean spherical refraction at final follow-up was 1.84±5.47 dioptres (D) (−8 to 10.75 D) and mean cylinder was −2.21±1.00 D (−1 to −4 D).
The endothelial cell loss in five patients who cooperated for specular microscopy ranged from 26.15% to 48% at 8 and 18 months postoperatively.
Discussion
While considering penetrating keratoplasty in a child, amblyopia management is challenging due to unstable and unpredictable refraction. DSEK, we believe, would provide a stable, more predictable refraction with faster visual recovery.
Surgically, DSEK can be more challenging in children as compared with adult eyes. Insertion and unfolding of donor lenticule in the small anterior chamber of a child, avoiding trauma to the crystalline lens, postoperative positioning, management of postoperative cataract and glaucoma are among the major concerns while considering DSEK in children. The use of an anterior chamber maintainer during the surgery helps in maintaining the anterior chamber depth throughout the procedure. We preferred to pass Sheet's glide across the pupil to the opposite angle to prevent inadvertent trauma to the crystalline lens. Staining with trypan blue dye and Chandelier illumination system6 can improve the visualisation.
The retrospective nature, small sample size, short follow-up, heterogeneity of the population in terms of indications of surgery, different techniques of donor dissection and influence of the astigmatism from the previous graft in cases of failed penetrating keratoplasty are major limiting factors. However, our study provides valuable information regarding the possible indications, surgical challenges and early outcomes of DSEK in children.
Acknowledgments
This study was supported by the Hyderabad Eye Research Foundation, Hyderabad, India.
Footnotes
Funding Funding provided by the Hyderabad Eye Research Foundation, India.
Competing interests None.
Patient consent Informed consent for all procedures was obtained from all patients Wavier applicable from the Institutional Review Board for retrospective study.
Ethics approval Ethics approval was provided by the Hyderabad Eye Research Foundation.
Provenance and peer review Not commissioned; internally peer reviewed.