RESUMEN
PURPOSE: To demonstrate the development of presumed immune-mediated stromal rejection after deep anterior lamellar keratoplasty and its reversal after initiation of intensive topical corticosteroid therapy. METHODS: Observational case report carried out with the approval of the hospital institutional review board. RESULTS: Stromal edema and peripheral vascularization developed 16 months after deep anterior lamellar keratoplasty for keratoconus in a 13-year-old girl. After 2 weeks of intensive topical corticosteroids, complete reversal of stromal edema and regression of peripheral vascularization occurred, with full recovery of visual function. CONCLUSION: The clinical appearance and response to therapy in this case support the diagnosis of immune-mediated stromal rejection. Ophthalmologists should be aware that sight-threatening stromal rejection may occur in lamellar corneal grafts.
Asunto(s)
Sustancia Propia/patología , Trasplante de Córnea/efectos adversos , Rechazo de Injerto/etiología , Prednisolona/análogos & derivados , Adolescente , Edema Corneal/tratamiento farmacológico , Edema Corneal/etiología , Neovascularización de la Córnea/tratamiento farmacológico , Neovascularización de la Córnea/etiología , Sustancia Propia/efectos de los fármacos , Femenino , Glucocorticoides/uso terapéutico , Rechazo de Injerto/tratamiento farmacológico , Humanos , Queratocono/cirugía , Prednisolona/uso terapéuticoRESUMEN
PURPOSE: To review current techniques used in deep anterior lamellar keratoplasty (LKP), and to describe a novel approach that facilitates baring of Descemet's membrane (maximum depth anterior lamellar keratoplasty). METHODS: A highly selective review of the literature is presented, with descriptions of different techniques in the light of the authors' personal experience over 3 decades. A novel method for baring Descemet's membrane is detailed. It involves air injection in such a way that a large bubble is created between stroma and Descemet's membrane. Visual results of this operation in patients with keratoconus are reviewed. RESULTS: Visual results 6 months after maximum depth anterior LKP in 181 eyes with keratoconus are comparable with those resulting from penetrating keratoplasty: 89% achieved a best spectacle-corrected visual acuity of 20/40 or better, and 10% achieved 20/20 or better. Intraoperative perforation occurred in 9% of cases. CONCLUSIONS: Maximum depth anterior LKP has some important advantages when compared with other types of anterior lamellar keratoplasty or penetrating keratoplasty, but it remains a challenging procedure. A new technique considerably facilitates this operation and reduces intraoperative complications.
Asunto(s)
Enfermedades de la Córnea/cirugía , Trasplante de Córnea/métodos , Lámina Limitante Posterior/cirugía , Aire , Humanos , Inyecciones , Técnicas de Sutura , Agudeza VisualRESUMEN
We describe a lamellar keratoplasty technique to bare Descemet's membrane in which air is injected to detach the central Descemet's. After a partial-thickness corneal trephination is performed, a disposable needle is inserted, deeply and bevel down, into the paracentral corneal stroma and air is injected. In most cases, this forms a large air bubble between Descemet's membrane and the corneal stroma. After anterior lamellar keratectomy is performed, a small opening is made in the air bubble and the remaining stromal layers are lifted with an iris spatula, severed with a blade, and excised with scissors. This technique is faster, safer, and easier to perform than previous methods.
