Late-onset Stromal Graft Rejection Triggered by Viral Conjunctivitis after Deep lamellar keratoplasty in Kerato-

conus

Sang Yoon Lee1,2, Sang-Mok Lee1,3, Won Ryang Wee1,2,

Jin-Hak Lee1,2, Mee Kum Kim1,2

Seoul Artificial Eye Center, Seoul National University Hospital Clini-cal Research Institute 1

Department of Ophthalmology, Seoul National University College of Medicine2

The armed forces capital hospital, Seoul National University College of Medicine3

The authors have no financial interest

Introduction

• Deep anterior lamellar keratoplasty (DALK)– Placing a donor corneal graft within a recipient corneal bed that is pre-

pared with removal of all recipient stromal tissue to Descemet’s mem-brane

– For patients with corneal stromal disease and normal endothelium like keratoconus

• Rejection in PKP & DALK– Endothelial rejection occurs in 20% to 30% of patients in PKP

• Most graft rejections occur in the first 3 years after keratoplasty• Most frequently over the first 12 months

– No endothelial rejection in DALK– Stromal rejection after DALK

Case (M/18)

B) Keratoconus VA (0.5/FC) Cornea B) bowing, central thinning

L) Deep anterior lamellar keratoplasty done

Postop 5 months Vos 0.7, Tos 15 Cornea : 10o/c new vessel appeared after broken suture developed, but

NV regressed after broken suture removed Ocumetholone q.i.d, 0.5% cyclosporine b.i.d.

Viral Conjunctivitis episode

Postop 21 months Vos (0.6), Tos 18 Graft : clear Medication : 0.05% cyclosporine b.i.d.

Postop 23 months B) Epidemic keratoconjunctivitis occurred for 2 weeks Graft : clear Medication : levofloxacin q.i.d., flumetholone q.i.d. for 2 weeks

Postop 23.5 months Vos (0.4) Conjunctiva L) follicular hypertrophy (-), injection (-) Graft : clear

Later Rejection developed

Postop 24 months C.C. acute visual loss (onset : 2 days ago) Vos (0.02) Assessment : L acute rejection Medication and Treatment

Predforte q1hour Prednisolone 60mg po qd

Previous NV d/t broken suture

Conjunctival injection

Diffuse stromal infiltration Endothelial edema

Rejection - regressing

Post-rejection 1 week Vos (0.15), Tos 11

Rejection - remission

Post-rejection 11 weeks, Post-PKP 27 months Vos (0.4), Tos 16-17 Medication

0.5% cyclosporine q.d. Ocumetholone q.i.d. He is a steroid responder. That is why we did not use high potency of steroid

Edema, stromal infiltration clear upSubepithelial opacity remained

Summary

DALK Acute rejection

(postop 24mo)

Viral conjunctivitis(postop. 23mo)

Remission(postop 27mo)

New vessel develop and regressed

(postop. 5 mo)

Steroid treatment

Discussion

• Rejection in PKP & DALK A few reports about stromal rejection in DALK

0%~8% of patients16 months~24 months after DALK

• Rejection & ocular inflammation Ocular inflammation is known as a risk factor of rejection in PKP. Previous report

Herpes keratitis Allergic conjunctivitis Atopic dermatitis Allergic airway hyperreactivitiy

No previous report about viral conjunctivitis

Conclusion

Acute stromal allograft rejection can occur 24 months after DALK.

Viral conjunctivitis seems to be able to trigger stromal graft rejection in DALK, which is known to have less tendency of rejection.

Reference

• Flynn, Obbayashi, et al. Effect of allergic conjunctival inflammation on the allogeneic response to donor cornea. Invest Ophthalmol Vis Sci 48(9): 4044-9

• Al-Torbak, Malak, et al. Presumed stromal graft rejection after deep anterior lamellar keratoplasty. Cornea 24(2): 241-3

• Wagoner, Ba-Abbad, et al. Postoperative complications after pri-mary adult optical penetrating keratoplasty: prevalence and impact on the graft survival. Cornea 28(4): 385-94

• Noble, Agrawal, et al. Deep anterior lamellar keratoplasty (DALK): visual outcome and complications for a heterogeneous group of corneal pathologies. Cornea 26(1): 59-64