Anterior segment analysis and intraocular pressure elevation after penetrating keratoplasty and posterior lamellar endothelial keratoplasty.

BACKGROUND: Peripheral anterior synechiae (PAS) is a common problem after penetrating keratoplasty (PK) and leads to intraocular pressure (IOP) elevation. This study examines the risk factors for IOP elevation and post-keratoplasty glaucoma. METHODS: A retrospective analysis was performed of 47 eyes following PK and of 65 eyes following Descemet's stripping endothelial keratoplasty (DSEK) between 2009 and 2011. The assessment included preoperative history of corneal disease and glaucoma, response to treatment, IOP, and visual acuity. Irido-trabecular contacts (ITC), the angle opening distance (AOD 500) and the anterior chamber angle (ACA 500) were calculated. RESULTS: The incidences of IOP elevation and post-keratoplasty glaucoma were 27-36% and 10-29%, respectively. The incidence did not differ significantly between both procedures. Pre-existing glaucoma increased the risk for developing IOP elevation and post-DSEK glaucoma. Eyes with bullous keratopathy (BK) developed significantly more IOP elevation (p = 0.01, d.f. = 1, χ(2) = 6.11) and post-keratoplasty glaucoma (p = 0.01, d.f. = 1, χ(2) = 6.22) than eyes with Fuchs' endothelial dystrophy. Eyes with ITC developed post-keratoplasty glaucoma significantly more often than eyes without ITC (p = 0.01, d.f. = 1, χ(2) = 6.63). CONCLUSION: IOP elevation and post-keratoplasty glaucoma showed a high incidence. Risk factors like pre-existing glaucoma, BK and PAS elevated the rate of IOP elevation and post-keratoplasty glaucoma for both procedures.

Posterior iris-claw aphakic intraocular lens implantation in children.

PURPOSE: To evaluate the indications, visual outcomes, and complication rate after posterior implantation of an iris-claw aphakic intraocular lens (IOL) in children. DESIGN: Noncomparative retrospective cohort study. METHODS: setting: Institutional practice. patients/intervention procedures: Seven eyes of 4 children without adequate capsular support had posterior chamber iris-claw aphakic IOL implantation between 2007 and 2012. main outcome measures: Visual acuity, endothelial cell changes, intraoperative and postoperative complications. RESULTS: The mean age of the 3 boys and 1 girl was 12.0 ± 3.4 (SD) years (range 8-16 years). In all eyes, the mean postoperative best spectacle-corrected visual acuity (0.13 ± 0.17 logMAR) was statistically significantly better at the last follow-up than at 1 day preoperatively (0.60 ± 0.39 logMAR) (P < .05). The mean follow-up was 31 months (range 10-64 months). The mean endothelial cell density decreased from 3013 ± 155 cells/mm(2) preoperatively to 2831 ± 236 cells/mm(2) at last follow-up, representing a mean endothelial cell loss of 6.4%. No corneal decompensation, iritis, secondary glaucoma, or pupillary block occurred after surgery in any eye. Postoperative complications included transient postoperative hypotony in 1 eye and a traumatic dislocation of a posterior aphakic iris-claw IOL in 1 eye. CONCLUSION: The posterior implantation technique of aphakic iris-claw IOL provided good visual outcomes with a favorable complication rate and can be used as a reasonable alternative for a wide range of indications in pediatric eyes without adequate capsular support.

Intraocular pressure elevation and post-DSEK glaucoma after Descemet`s stripping endothelial keratoplasty.

BACKGROUND: Intraocular pressure (IOP) elevation is a common problem in penetrating keratoplasty (PK), and possibly leads to graft failure. IOP elevation and secondary glaucoma may also be present after Descemet`s stripping endothelial keratoplasty (DSEK). This retrospective study analyzes the risk factors for IOP elevation and the functional outcome in those patients with post-DSEK glaucoma. METHODS: A retrospective analysis of case records of 72 DSEKs between 2007 and 2010 was performed. A total of 59 operated eyes were included. The assessment included the pre-operative history of corneal disease and glaucoma. Furthermore, the response to antiglaucoma treatment, the graft failure, the IOP, and visual acuity development were evaluated. RESULTS: The incidence of IOP elevation was 28.8 % and of post-DSEK glaucoma 11.9 %. Steroid-induced IOP elevation was the most frequent cause, with an incidence of 18.6 %. Patients with pre-existing glaucoma showed a significantly higher risk of developing IOP elevation, steroid-induced glaucoma and post-DSEK glaucoma (p = 0.006, p = 0.023, p = 0.009). In all cases, IOP elevation was treated effectively by tapering down steroid medication and initiating or increasing antiglaucoma medication. Visual acuity after 6 and 12 months improved significantly in cases with and without pre-existing glaucoma (p < 0.0001). After 24 months, clear grafts were achieved in 53 eyes (89.9 %). There was no significant difference in graft failure rates between cases with or without pre-existing glaucoma (p = 0.581) and with or without post-DSEK glaucoma (p = 0.306). CONCLUSIONS: IOP elevation after DSEK shows a high incidence. Pre-existing glaucoma increased the risk of developing IOP elevation and post-DSEK glaucoma. Although steroid-induced IOP elevation was the most frequent cause and could be treated effectively by tapering down steroid medication; there are other reasons why post-DSEK glaucoma developed. Management by medical treatment results in good visual acuity and graft survival.

Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty.

BACKGROUND: To evaluate the indication, visual outcome, and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL) during penetrating keratoplasty. METHODS: This retrospective study comprised 23 eyes (23 patients) without adequate capsule support undergoing posterior iris-claw aphakic IOL implantation (Verisyse/Artisan) during penetrating keratoplasty between 2005 and 2010. Mean follow-up was 18 months (range from 12 to 37 months). RESULTS: The IOLs were inserted during an IOL exchange in 17 eyes and as a secondary procedure in six aphakic eyes. Pseudophakic bullous keratopathy with corneal scar after anterior chamber intraocular lens (ACIOL) was the main indication for penetrating keratoplasty in 16 eyes (69.6 %). The final corrected distance visual acuity (CDVA) in logMAR (mean 1.0 ± 0.46) improved significantly (p < 0.05) compared to the preoperative CDVA (mean 1.8 ± 0.73). Twenty eyes (86.9 %) had a final visual acuity in logMAR better than the pre-operative CDVA. The mean postoperative IOP 16.3 mmHg ± 4.0 was not significantly (p > 0.05) higher compared to the preoperative IOP 15.6 mmHg ± 5.1. Complications included slight temporary pupil ovalization in three eyes (13.0 %) and iris-claw IOL sublocation in three eyes (13.0 %); all IOLs could be easily repositioned. Cystoid macular edema occured in one eye (4.3 %) 8 weeks after primary surgery. All grafts remained clear without any sign of graft rejection. CONCLUSIONS: Retropupillar iris-claw IOL during penetrating keratoplasty provides good visual outcomes with a favorable complication rate, and can be used for a wide range of indications in eyes without adequate capsule support.

Visual outcome and complications after posterior iris-claw aphakic intraocular lens implantation.

PURPOSE: To evaluate the indications, visual outcomes, and complication rate after implantation of a posterior chamber iris-claw aphakic intraocular lens (IOL). SETTING: Department of Ophthalmology, University Medicine Charité Berlin, Berlin, Germany. DESIGN: Retrospective case series. METHODS: Eyes without adequate capsule support had posterior chamber iris-claw aphakic IOL implantation (Verisyse/Artisan) between 2005 and 2010. RESULTS: The study comprised 137 eyes (126 patients). The mean follow-up was 5 months (range 1 to 48 months). The IOLs were inserted during primary lens surgery in 10 eyes (7.3%), during an IOL exchange procedure for dislocated posterior chamber IOLs in 95 eyes (69.4%), and as a secondary procedure in 32 aphakic eyes (23.3%). The final mean corrected distance visual acuity (CDVA) (0.38 ± 0.31 [SD] logMAR) was significantly better than preoperatively (0.65 ± 0.58 logMAR) (P < .05). In 128 eyes (93.4%), postoperative refractive errors were within ±2.00 diopters (D) of emmetropia. Complications included slight temporary pupil ovalization in 34 eyes (24.8%), cystoid macular edema in 12 eyes (8.7%), hyphema in 3 eyes (2.1%), early postoperative hypotony in 7 eyes (5.1%) and elevated intraocular pressure in 6 eyes (4.3%), chronic uveitis in 1 eye (0.7%), toxic anterior segment syndrome in 1 eye (0.7%), and endophthalmitis in 1 eye (0.7%). Iris-claw IOL disenclavation occurred in 12 eyes (8.7%); all IOLs could be easily repositioned. CONCLUSION: The retropupillary iris-claw IOL provided good visual outcomes with a favorable complication rate and can be used for a wide range of indications in eyes without adequate capsule support. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Relapses after surgical treatment of ocular adnexal basal cell carcinomas: 5-year follow-up at the same university centre.

PURPOSE: To define the efficacy of surgical resection of ocular adnexal basal cell carcinoma and to analyse possible risk factors, we determined relapse rates on a yearly basis postintervention in a cohort of patients that were treated in our hospital under comparable conditions. METHODS: A total of 366 such cases that were admitted for treatment between 2002 and 2006 were followed prospectively once yearly and tumour size and localization, histological type, functional and cosmetical outcome and relapses were recorded. In cases when the primary resection margins were not free, further resections were performed until the resection margin was histologically assessed tumour free on the basis of paraffin-fixed tissue sections. Lid reconstruction was carried out as direct closure, Tenzel rotation flap, tarsomarginal transplants or tarsoconjunctival flaps (Hughes), inversed rotation flaps, tarso marginal grafts, Cutler Beard flaps, free skin grafts, rhomboid, glabella or advancement flaps. Relapse-free survival 3, 4 and 5 years postoperatively was estimated by the Kaplan-Meyer method. RESULTS: Three relapses after 3 years and two further relapses after 5 years were recorded. An additional relapse was documented 6 years postoperatively. Accordingly, the relapse-free survival was 0.99 (95% CI 0.98-1.00) after 3 years, 0.99 (95% CI 0.97-1.00) after 4 years and 0.97 (95% 0.95-0.98) after 5 years. The relapses occurred in previously relapsed tumours and in tumours of morphea type. Primary nodular basal cell carcinomas did not relapse in this study. CONCLUSIONS: Based on these studies and in comparison with published relapse rates after cryotherapy, surgical resection appears to be superior to the latter procedure.

Endothelial evaluation in the cornea bank.

The light microscope is the first-choice technique for the evaluation of organ-cultured donor corneas. For the microscopic visualization of the endothelial cells, the corneas have to be immersed in ahypotonic solution. The number of cells, their vitality and morphology are analyzed. The cell densityis easily estimated with the fixed frame/L method. Use of an image analysis system enables computer processing and counting of digitalized endothelial cell images. An adequately high endothelial cell density after the culture period is a decisive criterion that must be met before releasing adonor cornea for grafting. An endothelial cell density of 2,000-2,200 cells/mm2 is generally recognized as the lower limit for the longest possible graft survival. While an evaluation of the endothelium does not necessarily have to be performed at the beginning or middle of organ culture, it isobligatory at the end. Morphology assessment should routinely involve estimating the pleomorphism (deviation from hexagonality), polymegathism (variation in cell area) and granulation/vacuolization of the endothelial cells. Recognition of devitalized cells is easily facilitated by vital stainingwith trypan blue.

Influence of temporary hypothermia on corneal endothelial cell density during organ culture preservation.

PURPOSE: To evaluate temporary exposure to hypothermia for its effects on endothelial cell density of porcine corneas in dextran containing organ-culture medium, with regard to possible negative influences of low temperatures during the transport of corneal grafts. METHODS: Two groups of central discs from pig corneas (diameter 8 mm) were first organ-cultured (MEM with 6% dextran 500) for 24 hours at 32 degrees C. Twelve corneas were exposed to 4 degrees C in group 1 for 12 hours and to 21 degrees C in group 2 for 48 hours each. The paired corneal discs were not treated, and served as controls. After further organ culture of all corneas for 48 hours at 32 degrees C to allow regenerative processes, corneal endothelium was stained with alizarin red S and examined by light microscopy. The endothelial cell densities were determined manually on three central images. RESULTS: Exposure for 12 hours to 4 degrees C as well as for 48 hours to 21 degrees C induced an endothelial cell loss of 0.3% and 1.8% respectively. Statistical analysis showed no significant difference (p = 0.680) of the endothelial cell density between corneas exposed to 4 degrees C and the control corneas (4166 +/- 389 cells/mm(2) and 4177 +/- 407 cells/mm(2) respectively). Despite the minor cell loss, the difference of the endothelial cell density between corneas exposed to 21 degrees C and the control corneas (4085 +/- 260 cells/mm(2) and 4159 +/- 312 cells/mm(2) respectively) was statistically significant (p = 0.025). CONCLUSIONS: Exposure of organ-cultured porcine corneas in dextran containing medium to 4 degrees C for 12 hours and 21 degrees C for 48 hours does not compromise the endothelial cell density of donor corneas in a clinically relevant manner. A storage of corneal grafts at temperatures down to 4 degrees C for 12 hours, as might be the case during transport from the cornea bank to the ocular surgeon, does not seem to damage the endothelial cell layer.

Endothelial cell density in porcine corneas after exposure to hypotonic solutions.

PURPOSE: To evaluate exposure to sucrose solution (1.8%) and hypotonic balanced salt solution (BSS) for its effects on endothelial cell density of porcine corneas. METHODS: Two groups of central discs from pig corneas were organ-cultured for 24 h. Twelve corneas per group were exposed to sucrose solution (1.8%) or hypotonic BSS for 4 min each. The paired corneal discs were not treated and served as controls. After further organ culture with and without dextran for 48 h, corneal endothelium was stained with alizarin red and examined by light microscopy. The endothelial cell densities were determined manually on three central images. RESULTS: The endothelial cell density differed significantly between corneas exposed to sucrose and the control corneas (3982+/-382 cells/mm(2) and 4360+/-331 cells/mm(2) respectively, and 3876+/-364 cells/mm(2) versus 4374+/-168 cells/mm(2) respectively with 6% dextran). In contrast, the endothelial cell density did not differ significantly between corneas exposed to hypotonic BSS and the control corneas (4374+/-296 cells/mm(2) and 4317+/-193 cells/mm(2) respectively, and 4348+/-151 cells/mm(2) versus 4426+/-175 cells/mm(2), respectively with 6% dextran). CONCLUSIONS: Exposure to 1.8% sucrose for 4 min induces a significant endothelial cell loss of 10% on average, whereas exposure to hypotonic BSS did not significantly influence the endothelial cell density.

Medial canthal reconstruction by a modified glabellar flap.

AIMS: To present a modified technique for the preparation of glabellar skin flaps to reconstruct medial canthal defects. METHODS: Ten consecutively treated patients were included who had skin defects after resection of skin tumours like basal cell carcinomas in the medial canthal area of a medium vertical diameter of 2.5 cm. The defects were closed by preparation of a modified glabellar flap. The pedicle of the flap was guided through a skin tunnel prepared diagonally at the root of the nose. The pedicle was resected 4 weeks after the initial surgery. RESULTS: In all 10 cases, the procedure was adequate for reconstruction of the defect. There were no flap necroses and the cosmetic results were favourable in all cases. The resection of the pedicle could be performed easily in an out-patient procedure 4 weeks after the operation. CONCLUSION: Glabellar flaps are established procedures to reconstruct medium to large defects of the medial canthus. Skin distortion in the area of the flap pedicle leading to a skin bulge and visible scars at the root of the nose and medial transposition of the eye brows can be reduced by a modification of the surgical technique preparing a skin tunnel for the flap pedicle. In our hands, the cosmetic results are better with the modified technique in comparison to the original procedure.

Risk factors for endothelial cell loss post-keratoplasty.

PURPOSE: Transplant survival following penetrating keratoplasty is determined to a large extent by the course of endothelial cell density loss. Different influencing factors such as organ culture conditions, surgical trauma, exchange between donor and recipient cells, cell ageing and immune reactions can contribute to endothelial cell loss. The aim of this study was to determine the rate of endothelial cell loss in our patients and to detect dependencies on donor-and recipient-related factors. METHODS: Using non-contact specular microscopy, endothelial cell counts were obtained every 6 months from 293 consecutive patients who underwent keratoplasty in our institution between 1996 and 2000. Follow-up time was 36 months. RESULTS: In comparison with the density of donor endothelial cells, the mean endothelial cell loss of patients was 28.8% after 6 months, 39.8% after 12 months and 49% after 24 months. Donor age and initial cell density did not have a significant influence on the course of endothelial cell loss. The lowest rate of endothelial cell loss was associated with patients diagnosed with keratoconus. Conversely, those with preoperative glaucoma had a significantly increased rate of endothelial cell loss (p < 0.05). CONCLUSIONS: This study shows that preoperative glaucoma is a major risk factor for increased endothelial cell loss following keratoplasty.

Late spontaneous in-the-bag intraocular lens and capsular tension ring dislocation in pseudoexfoliation syndrome.

Two patients with pseudoexfoliation syndrome (PEX) in whom late spontaneous in-the-bag intraocular lens (IOL) and capsular tension ring (CTR) dislocation occurred 3 and 6 years after cataract surgery are described. The patients received CTRs because of phacodonesis due to zonular laxity. The IOLs were centered postoperatively, and there was no postoperative ocular trauma. In both cases, removal of the IOL and CTR within the capsular bag was performed uneventfully by a scleral tunnel incision and an anterior chamber IOL was implanted. Capsular tension ring implantation in PEX-associated zonular weakening does not guarantee long-term zonular stability and capsular bag/IOL position in these patients after cataract surgery.

Polyurethane stents for lacrimal duct stenoses: 5-year results.

PURPOSE: To present 5-year results of polyurethane stent implantation for treatment of postsaccal lacrimal duct stenoses. METHODS: Ninety-two consecutive patients admitted to our hospital for stent implantation between 1997 and 2001 were retrospectively analysed. The patients who were not re-treated in our clinic were asked by questionnaire about their satisfaction and complaints. RESULTS: In 5 patients (5.4%) the implantation was not completed, 38 patients (41.3%) were re-treated due to relapsing epiphora during follow-up, and 11 stents (12.0%) were removed by dacryocystorhinostomy (DCR). Five stents (5.4%) were extracted transnasally. Four stents (4.3%) were removed in another hospital. Eighteen patients (19.6%) had relapsing epiphora but have not been re-treated so far. Forty-nine of 92 patients (53.3%) were not re-treated in our clinic and were interrogated by means of a questionnaire. Twenty-seven answered (55.1%), 8 did not answer (16.3%) and 14 patients (28.6%) did not receive the letter because they had moved away or died. Only 12 of the patients who answered the questionnaire had no or slight complaints (44.4%, or 18.5% of all treated patients). CONCLUSIONS: The long-term success rate of polyurethane stent implantation is very low (18.5%).

Outcome of rotational keratoplasty: comparison of endothelial cell loss in autografts vs allografts.

BACKGROUND: The nature of chronic endothelial cell loss in homologous corneal grafts is still unclear. Possible causes are cell migration to the recipient bed and chronic subclinical immune reaction. OBJECTIVES: To compare endothelial cell loss after autologous rotational keratoplasty and homologous keratoplasty and present the clinical outcome of patients after rotational keratoplasty. METHODS: In this open prospective study, we included 7 consecutive patients who underwent rotational keratoplasty between 1998 and 2000 in our hospital. Patients were examined clinically every 3 months, and visual acuity, astigmatism, and endothelial cell density were evaluated. Endothelial cell densities were compared with endothelial cell counts of 293 homologous keratoplasties. RESULTS: Mean follow-up for autologous grafts was 39 months. Mean increase in visual acuity was 3.5 lines. Mean astigmatism was 4.75 diopters in the autologous graft group. Mean preoperative endothelial cell density was 2058 (637 cells/mm(2)). Mean endothelial cell density after 1 year was 1865 (639 cells/mm(2)), which represents a mean +/- SD cell loss of 15% +/- 7.19%. At the end of follow-up, endothelial cell number after autologous grafting was 1630 +/- 622 cells/mm(2). Endothelial cell loss after 1 year in homologous grafts was 40% +/- 21.34%. There was 1 decompensation of autologous graft in the follow-up period. Main Outcome Measure Comparison of endothelial cell count at different postoperative time points using nonpaired t test. CONCLUSIONS: Endothelial cell loss in autologous grafts is significantly lower than in homologous grafts, which supports the hypothesis that chronic endothelial cell loss is due to chronic subclinical immune reactions in homologous grafts. Autologous keratoplasties can lead to good functional results and can be superior to homologous corneal grafting in suitable situations.

Fibroblast growth factor-2 protects endothelial cells from damage after corneal storage at 4 degrees C.

BACKGROUND: Since the introduction of cold corneoscleral segment storage prior to keratoplasty there have been continuous efforts to ameliorate the preservation media in order to better maintain the quality of the corneal epi- and endothelium. Recent studies have shown that basic fibroblast growth factor (FGF-2) preserves the viability of, for example, retinal ganglion cells and pigment epithelium cells. Therefore, we investigated the effect of different concentrations of FGF-2 added to a modified Optisol storage medium on endothelial damage after corneal storage at 4 degrees C. METHODS: . Bovine corneas were stored at 4 degrees C for 14 days and for another 24 h at 34 degrees C. Various FGF-2 concentrations (4, 20 and 40 ng/ml) were added to the medium either at day (D) 1, D14, or both D1 and D14. Quantitative evaluation of corneal damage after 14+1 days of storage was conducted by means of the Janus green photometry assay. Histological and ultrastructural investigations of the preserved endothelium were also performed. Bovine cell culture experiments using the TUNEL assay aimed to elucidate the role of FGF-2 on prevention of endothelial apoptosis. RESULTS: The mean endothelial damage in control corneas increased from 4.9 +/- 1.8% (fresh corneas) to 13.4 +/- 2.4% after 14+1 days of storage. FGF-2 at 20 ng/ml or 40 ng/ml added at any of the indicated time points significantly reduced the overall endothelial damage by 5.1-7.3%, corresponding to 38-54% less endothelial damage than in control corneas (P<0.001). Light- and electron microscopic investigations confirmed this protective effect of FGF-2 on corneal endothelial cells. The TUNEL assay revealed a true anti-apoptotic effect of FGF-2 on endothelial cells in culture. CONCLUSION: Our study clearly demonstrates the effectiveness of FGF-2 to enhance cell survival of the corneal endothelium after storage at 4 degrees C. A clinical interest could be seen in the potential future application of FGF-2 as an adjuvant to corneal preservation media in order to better maintain endothelial viability during corneal storage.

Increased endothelial survival of organ-cultured corneas stored in FGF-2-supplemented serum-free medium.

PURPOSE: To investigate the effect of FGF-2 on corneal endothelial cell survival in porcine and human corneas during corneal storage in a serum-free medium. METHODS: Porcine and paired human corneas were stored at 32 degrees C for 9 and 22 days, respectively. One cornea of each pair was stored in a serum-free culture medium, and the mate was preserved in the same medium supplemented with 10 ng/mL FGF-2. Quantitative analysis of corneal damage after storage was determined by the Janus green photometry technique. 5-Bromo-2-deoxyuridine (BrdU) labeling of the endothelium determined the effect of FGF-2 on endothelial proliferation during storage. Additional cell culture studies were performed to elucidate the role of FGF-2 on the incidence of endothelial apoptosis after serum deprivation. RESULTS: When FGF-2 was added to the serum-free medium, the damage rates of porcine endothelia were reduced from 15.1% +/- 8.7% (control) to 6.4% +/- 2.0% after 9 days and from 25.3% +/- 10.2% to 13.6% +/- 4.2% after 22 days of storage. In the human corneas stored during 22 days in FGF-2-supplemented medium, the amount of endothelial damage was 11.8% +/- 3.2%, which was significantly less damage than in the control fellow corneas stored in unsupplemented serum-free medium (19.3% +/- 6.3%; P < 0.01). DNA synthesis was not enhanced in corneas stored in serum-free medium, serum-free medium+FGF-2, or medium containing 10% FCS. Only a few (3.8%) TUNEL-positive endothelial cells were detected in cultures maintained in FGF-2-supplemented serum-free medium compared with a high number (48%) of apoptotic cells in control cultures. CONCLUSIONS: FGF-2 efficiently reduces human corneal endothelial damage that occurs during organ culture storage in a serum-free medium. This effect is truly protective, because no proliferative activity and a decreased rate of apoptosis were determined. FGF-2 emerges as an important component of a future serum-free corneal organ-culture medium established to replace fetal calf serum (FCS) as a potential source of recipient infection.

Outcome of penetrating keratoplasty in rheumatoid arthritis.

BACKGROUND: Keratolysis in rheumatoid arthritis is a well-known disorder that may rapidly destroy the entire corneal stroma, resulting in descemetocele formation and eventually corneal perforation. The purpose of this study was to determine the anatomical and functional results of therapeutic penetrating keratoplasty (PK) in these patients. PATIENTS AND METHODS: We reviewed the charts of patients having undergone PK over a 5-year period and evaluated the outcome. In 16 eyes of 15 patients, PKs were performed (graft diameter 3.0-11.0 mm) because of corneal melting with perforation or descemetocele formation. In 9 eyes, we used topical cyclosporine A (2%) as an adjunct therapy after transplantation in addition to systemic immunosuppressive agents. RESULTS: Following a mean follow-up time of 17 months, anatomical success could be achieved in all eyes; none of the eyes underwent enucleation or evisceration. Postoperative complications following the first PK were epithelial keratopathy in 8 eyes (50%), corneal ulceration in 5 eyes (31%), fistulation in 4 eyes (25%), suture loosing in 4 eyes (25%) and graft rejection in 2 eyes (13%). Additionally 5 regrafts were required because of recurrence of corneal melting or persistent deep stromal defects. Comparison of complications of the patients receiving topical cyclosporine A to the control group showed a statistically significant lower incidence of epithelial keratopathy (p < 0.025) and ulcer recurrence in the cyclosporine A group during the first 3 months postoperatively (p < 0.05). The final best corrected visual acuity was 20/40 in 4 eyes but was limited to 20/200 or less in 7 eyes. CONCLUSION: Whereas PK can be successful to restore the anatomical integrity of severely altered eyes, the high prevalence of complications limits the indication for PK as a last stage procedure when other methods of management have failed. The use of topical cyclosporine A as adjunct therapy needs further evaluation.