Indications for and Outcomes of Therapeutic Penetrating Keratoplasty

Sonika Gupta Consultant Ophthalmology Max Eye Care New Delhi, India

Author has no financial interest

Purpose /Methods

• To evaluate the indications and outcome of Therapeutic Penetrating Keratoplasty (TPK).

• Retrospective review of records of 104 consecutive patients (104 eyes) who underwent TPK was carried out.

• Review included age, gender, indication for surgery, surgical details, post-operative complications, visual and anatomical outcome of surgery

METHODS

Selection of cases– Eyes with infective

keratitis had routine diagnostic smear and culture performed.

– Medical therapy was the first line of treatment.

Methods

– Indications for TPK were:

• Corneal ulcer refractory to maximal medical therapy

• Perforation more than 3mm

• Descemetocele with infiltrates

– Regrafts were not included in the study.

Methods- Surgical procedure

• Donor corneas were obtained from the corneoscleral button preserved in McCarey Kaufman culture medium.

• The donor button was oversized by 0.5mm and punched from endothelial side of the corneoscleral button.

• Host trephine size was selected to cover the infiltrate edge of the ulcer completely.

• The anterior chamber was irrigated to remove any inflammatory debris.

Methods- Surgical details

• Viscodissection of the angle was done to ensure thorough cleaning of the anterior chamber of any exudate and release any peripheral anterior synechiae.

• Cataract, if present was not disturbed unless lens was found subluxated.

• In eyes with aphakia or vitreous loss, anterior vitrectomy was done

• The donor button was sutured to the host with 16 interrupted 10-0 monofilament nylon suture bites.

• Suture knots were trimmed and buried towards the donor side.

RESULTS

• Total no. of patients = 104 (104 eyes).

• Mean age of patients 45.78 ± 18.68 years

• 81 males (77.8%) 23 females (22.1%).

• Mean follow up = 18 months.

Results

Indications for TPK in this study (also shown in pie-chart in next slide)–

• perforated corneal ulcer n=35• non healing fungal keratitis n=35• non healing bacterial keratitis n=21• mixed infective keratitis n=7• non healing viral keratitis n=2 • traumatic corneal perforation n=2 • chemical melt n=2

Main Indications for TPK

0

10

20

30

40

50

60

70

80

90

2nd Qtr 3rd Qtr 4th Qtr

East

West

North

2%

2%

2%

7%

20%

34%

33%

perforatedcorneal ulcer

non healingfungal keratitis

non healingbacterialkeratitis

mixed infectivekeratitis

non healingviral keratitis

traumaticcornealperforation

Outcome of TPK

• Anatomical integrity was achieved in 101 eyes (97.1%).

• 3 eyes were phthisical.• Clear grafts seen in 42

eyes (40.3%)

Results

• Post op vision remained the same in 64 eyes (62.4%)

• 16.3% eyes had vision ≥ 20/200• Causes of graft failure were ocular surface

disease 25.0 %, graft infection 16.3%, glaucoma 7.69 %, graft rejection 5.76 %

and primary graft failure 4.80%.

CONCLUSION

• TPK is successful in maintaining the anatomical integrity of the eye.

• TPK has an important role in salvaging the eyes with active uncontrolled infection or perforation from corneal disease.

• Lower number of clear grafts in our study could be due to delay in presentation by the patient leading to delayed surgical intervention, lack of availability of good quality donor tissue and inadequate compliance with follow-up.