Keratoplasty associated complicationsDR. KARAN BHATIAFELLOW CORNEA, PHACOEMULSIFICATION AND REFRACTIVE SURGERYMM JOSHI EYE INSTITUTE, HUBLI, KARNATAKA, INDIA

Introduction The history of "tissue transplantation" starts from Adam and Eve in Eden. Throughout history, however, the eye, as the avenue to the Sun God, has symbolized virtue and wisdom, with blindness as a penalty for impiety and the stigma of sexual shame. Blind people were generally regarded as social outcasts, for whom treatment of any sort represented a tampering with God's proper judgment. In myths and folklore, although occasionally the damaged eye was replaced by the fresh one, the eye is more usually replaced by its symbolic equivalent of wisdom or second sight.

DefinitionCorneal transplantation or grafting

is an operation in which abnormal corneal host tissue

is replaced by healthy donor cornea

Post-operative complicationsEARLY

◦ Shallow AC & Wound Leak◦ Iris Incarceration◦ Wound Dehiscence◦ Suture-Related Problems◦ DMD◦ Epithelial Defects◦ Filamentary Keratitis◦ Primary Graft Failure◦ Graft Rejection◦ Hyphema◦ High IOP & Pupillary Block Glaucoma◦ Low IOP◦ HSV Keratitis◦ Microbial Keratitis◦ Endophthalmitis

LATE (MONTHS, YEARS)

◦ Graft Rejection◦ Infectious Crystalline Keratopathy◦ Urretz-Zavalia Syndrome◦ Corneal Membranes◦ Hurricane (Whorl) Keratopathy◦ Cataract◦ Astigmatism◦ Glaucoma◦ Recurrence of Original Recipient disorder◦ Disease transmission from Donor Cornea◦ VR Problems

◦ RD◦ Macular edema

Early Post Operative ComplicationsVARY FROM MINOR TO TRUE OPHTHALMIC EMERGENCIES LOSS OF EYEMETICULOUS FOLLOW UP, EARLY DIAGNOSIS, TIMELY INTERVENTION MANDATORY

Shallow AC & Wound Leak• Shallow AC with Low IOP on POD1 Wound Leak

• IOP – normal/high – in some eyes

• Siedel’s test

• Prolonged Shallow ACSecondary glaucomaSignificant endothelial loss

• Causes Broken, Loose or misplaced sutureSuture track leak full thickness sutureSuture through thin or necrotic tissueExcessive gap between suturesUnequal thickness of graft and host

Shallow AC & Wound Leak – Prevention & ManagementAnterior Chamber

Flat

Wound suture tract leak or iris prolapse

Surgical Repair (immediately)

Formed

Wound Leak +

Pressure Bandage or BCL, Acetzolamide

If wound does not seal in 24 hours

Resuture

Interrupted sutures – replace loose/broken sutures Place additional suture in place of leak Continuous suture – loosen tight area and tighten area of

leak (redistributes tension) Suture tract leak – usually close spontaneously/ additional

mattress suture applied perpendicularly Corneal gluing & Bandage – for leak through necrotic tissue

Iris Incarceration• Causes

Collapse of AC/wound leakInflamed eyes/ Swollen & Flaccid Iris (preop)Poorly placed sutures

• Closes AC angle at site incarceration GlaucomaGraft failure

• Large adhesions at host-graft junction localized graft edema vascularization

Wound Dehiscence• Can occur immediately/several years later

• CausesTraumaInfectious KeratitisSuture FailureSpontaneous wound separation

• Resuture immediately

Suture Related ProblemsExposed

knotBroken suture

Tight suture

Loose suture

Unraveled suture knot

Suture abscesses Immune infiltrates

Vascularization

FB SensationGPCVascularizationNidus for infection

Persistent epithelial defects

Nidus for infection

ExposedFails to epithelize

Can loosen, become exposed or act as nidus

Poor prognostic factor for graftsCan lead to –• wound dehiscence• graft failure secondary

to infection• corneal scarring• endophthalmitis

Immunological reaction to suture material/ talc from surgical gloves

Hypersensitivity reaction to Staph albus (colonizes lid margins)

Rotation/ Replace with knot burried

Remove Replace Remove Debride suture roof, Suture & send for microbiological examBroad spectrum antibiotics

Topical steroids+ ciclosporin A

Immune suture infiltrates Infectious suture infiltrates

Multiple/small SolitaryOnly on host side Can occur on host/ graft sideNot associated with epithelial defect Epithelial defect common

Broken Suture

Tight Suture

Suture Infiltrates Suture induces Vascularization

Protruding suture with vascularization

Papillary hyperplasia

Descemet Membrane Detachment• Intracameral Air or C3F8/SF6 or viscoelastic

• Transcorneal Suturing

• Corneal Transplantation

Epithelial Defects• Re-epithelialization and maintenance of intact epithelium essential for post-op wound healing & Survival of graft

• Persistent >2-4 days without progress or healing

• Average time for complete epithelization – 4-6 days

Epithelial defects (contd) – Risk Factors

Ocular Surface Disorders

• Lid abnormalities – ectropion, entropion, lagophthalmos

• Infection & Inflammation – HSV

• Iatrogenic – tight sutures, dryness, poor apposition of graft-host junction

• Epitheliotoxic drugs – gentamicin, timolol, ciprofloxacin, prednisolone, dorzolamide, NSAIDs

•Damaged donor epithelium

•Basement membrane disorders

•Intrinsic epithelial disorder – Stem cell deficiency secondary to thermal/ chemical burns, SJS, Ocular cicatrical pemphigoid

•Trauma

•Poor nutrition – Vitamin A deficiency, PEM

•Metalbolic diseases – DM (both in donor and host)

Epithelial defects (contd) – Management• Prevent and Treat Risk Factors

• Adequate lid closure

• Prevent Corneal Exposure

• BCL

•Temporary Tarsorrhaphy

• Choramphenicol/ Panthogel

• Autologous Serum

• AMT

• HSV – Oral Acyclovir 300 mg BD

Filamentary Keratitis Reported Incidence of 27% in one case series*

*Rotkis WM et al. Filamentary Keratitis following penetrating keratoplasty. Ophthalmology. 1982;89:946-9.

Primary Graft Failure• Gross Corneal Edema in Graft with large broad folds immediately after keratoplasty

•Usually develops in POD1

• Not followed by a period of clear cornea

•Incidence <5% *

• Faulty donor tissue – results in irreversible graft edema in immediate post-op period

• Factors –Prolonged death-enucleation timePoor donor endothelial countAphakic and pseudophakic donorElderly donor Inadequate preservationSurgical traumaHSV infection

* Wilhelmus KR et al. Primary corneal graft failure. A national reporting system. Medical advisory board of Eye Bank Association of America. Arch Ophthalmol 1995;113:1497-502

Primary Graft Failure (contd)• Unresponsive to hypertonic saline/ steroids

•Proper donor selection

•Prolonged death to enucleation time – MK media can preserve donor tissue only up to 2 hours

•Early surgery & Minimal surgical trauma

•Observe for 3-4 weeks. No improvement Repeat Penetrating Keratoplasty

Graft Rejection•Graft clear for atleast 2 weeks graft edema + inflammatory signs

Hyphema•Incidence increases with intraoperative manipulations like extensive synechiolysis, iridoplasty or iridotomy

•Clears spontaneously without treatment

•IOP high – then treat aggressively

•Β-Blockers + Briminodine/Acetazolamide

•Prolonged persistence – Clot irrigation and aspiration

High IOP & Pupillary Block Glaucoma

Due to –

•Residual viscoelastics in AC

•Uveitis

•Hyphema

•Crowding of AC angle

•Pupillary block

•Forward movement of lens iris diaphragm

FLAT/ Shallow AC with closely secured wound (Siedel’s Negative) Pupillary block/ Choroidal detachment

Choroidal detachment – low IOP

Low IOP Causes –

•Wound Leak

•Iridocyclitis: Ciliary shock

•Cyclodialysis

•Choroidal detachment

•Retinal Detachment

HSV Keratitis•HSV Keratitis can incite graft rejection and vice versa

• Patterns –DendriticGeographicStromal – graft edema, KPs – difficult to distinguish from graft

rejection

However, HSV – focal involvement, propensity to occur at graft host junction

Absence of Khadadoust Line

•Topical Acyclovir 5 times/day x 2 weeks Post-op

•Oral Acyclovir 400 mg BD/ Valacyclovir 500 mg BD x 1 year

Microbial Keratitis• Incidence higher in developing countries• ½ occur within 1st 6 months of surgery• Either infection within graft/ along suture tracts at

graft host junction

Inflammatory Reaction

Initiation of Graft Rejection

Graft Failure Graft MeltingEndophthalmitis

• Corneal scrapings – Gram’s stain/KOH/C & S• Therapy modified based on lab report• Initial therapy – Fluoroquinolone or combination of

Cefazolin 5% and Tobramycin 1.3%

Endophthalmitis• Vitreous Tap

•Intensive topical, intravitreal and systemic antibiotics

Late Post-operativeMONTHS, YEARS

Graft Rejection

Ciliary Injection in pre-rejection Elevated epithelial line in epithelial rejection

Krachmer Spots in Stromal Rejection Endothelial Rejection (Khoudadoust line)

Infectious Crystalline Keratopathy•Chronic, progressive corneal infection

•Anterior lamella of graft involved

•No clinically evident stromal inflammation

•Crystalline branching opacities in anterior & mid stroma

Urrets-Zavalia Syndrome•Permanent fixed dilated pupil after penetrating keratoplasty/DALK in patients with keratoconus

•Iris atrophy

•Secondary glaucoma

•Mydriasis unresponsive to miotics

•Unknown etiology (severe iris ischaemia – possible mechanism)

•Management –• Reduce IOP• Avoid Atropine pre-operatively• Peripherally painted Contact Lens for photophobia, glare

Corneal Membranes Epithelial ingrowth (conjunctival/corneal) – through gap at host-graft junction

Fibrous ingrowth (retrocorneal membrane) – gray/white fibrous membranes between DM and endothelium

Hurrican (whorl)/ Vortex Keratopathy

Cataract•Incidence varies from 25-80% *

•Due to –Poor surgical techniqueAltered lens metabolismToxic – corticosteroids, anticholinesterase

*Rathi VM et al. Cataract formation after Penetraing keratoplasty. J Cataract Refract Surg. 1997;23:562-64

Astigmatism•Average – 4-5 D

•Higher in eyes with – Scarring due to corneal ulcerKeratoconusEccentric graftMal-aligned graftFaulty suturing techniques

Improper placement of second suture Unequal depth Non-radial sutures Tight sutures Unequal distribution of tension in continuous suture

Surgical Caveats to minimize Astigmatism

•Central and sharp trephination

•Use of a sharp trephine

•Symmetric suture placement (especially 2nd suture)

•Avoid tight suture placement

•Suture adjustment (for continuous suture) or selective suture removal (for interrupted sutures)

Glaucoma•Due to PAS and epithelial downgrowth

•2 unique mechanisms –Collapse of trabecular meshworkCompression of AC angle

•Larger Donor Grafts – associated with deeper AC lower incidence of post-op progressive angle closure and lower post-op IOPs

•Avoid Dorzolamide

•Laser Trabeculoplasty

•Trabeculectomy with MMC GDD Surgery

Recurrence of Original Recipient Disorder•Due to migration of recipient keratocytes into graft stroma

•Occurs frequently in –Granular – 100% at 4 years*Macular – 5.2%**Lattice – 48%***Reiss Buckler’s dystrophyCentral crystalline dystrophyPosterior Polymorphous dystrophy

•Repeat graft

•Superficial keratectomy/ Excimer laser Phototherapeutic keratectomy – for superficial lesions

*Lyon CJ et al. Granular corneal dystrophy. Visual results and pattern of recurrence after lamellar or penetrating keratoplasty. Ophthalomology 1994;101:1812-17** S. Al-Swailem A et al. Penetrating keratoplasty for macular corneal dystrophy. Ophthalmology. 112(2):220-24*** Meisler DM et al. Recurrence of clinical signs of lattice corneal dystrophy (type I) in corneal transplants. Am J Ophthalmol. 1984;97:210-14

Vitreoretinal problems Retinal Detachment

•Rare

•Incidence increases with complicated procedure, especially after vitreous manipulation

Macular Edema

•Common cause of non improvement of vision despite clear graft

•Predispositions –Aphakic bullous keratopathyPseudophakic bullous keratopathyTraumaAny previous intraocular surgery

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