Corneal Graft in Children - Pakistan Journal of Ophthalmology

Original ArticleCorneal Graft in ChildrenMunira Shakir, Syeda Aisha Bokhari, Shakir Zafar, Zeeshan Kamil, Syed Fawad RizviPak J Ophthalmol 2012, Vol. 28 No. 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .See end of article forPurpose: To share our experience of penetrating keratoplasty in children at aauthors affiliationstertiary care hospital…..………………………..Correspondence to:Munira ShakirHouse No. 61L.R.B.T Free Base EyeHospital, KarachiKorangi 2 1/2 , Karachi.Postal Code- 74900…..………………………..Material and Methods: In this study, records of pediatric keratoplasty performedon 90 eyes in 85 children of less than 14 years of age at the PediatricDepartment of LRBT Free Base Eye Hospital Karachi, for the period of 3 yearsfrom January 2006 to December 2008 were reviewed.Results: Out of 85 patients, 45 (52.94%) were boys and 40 (47.05%) were girls.Indications were scarring after keratitis in 16 (17.7%) eyes, traumatic cornealscarring in 16 (17.7%), corneal dystrophies 22 (24.4%), keratoconus andhydrops in 26 (28.8%), chemical injury in 8 (8.8%) and congenital glaucoma in 2(2.2%). Total 65 out of 90 (72%) eyes showed clear cornea at final follow up.Grafts performed for keratoconus were the most successful in terms of graftsurvival, which accounted for 23 out of 26 (88.46%) eyes. Improvement in visualacuity was recorded in 64 out of 90 (71.11%) eyes. Best corrected visual acuityof 6/24 or better was achieved in 22 out of 90 (24.44%) patients.Conclusion: In conclusion, our experience of keratoplasty in pediatric age groupyielded promising results.Keratoplasty is one of the world’s most widelypracticed human organ and tissue transplanttationmethod 1 . Corneal grafting is usuallyindicated for optical reason to restore visionoccasionally it may be performed for cosmeticappearance of the eye 2 .Modern day success in transplantation isattributed to eye banking, storage techniques, ocularpharmacology, equipment and modern surgicaltechniques 3 . Paedriatic keratoplasty is a difficultundertaking, which presents a wide range ofchallenges pre-operatively, intra-operatively and postoperatively4 . Successful restoration of vision withpaediatric keratoplasty has only been achieved in thepast two to three decades 5 . Previously pediatriccorneal transplantation was consideredcontraindicated in children, 6 because of the technicalchallenges in pediatric anterior segment surgerycreated by low scleral rigidity and forwarddisplacement of lens-iris diaphragm. In children, thepotential for post-surgical anterior segmentinflammation may lower scleral rigidity whichincreases the likelihood of significant refractive errorsafter corneal transplantation. The underlying diseaseprocess will also influence the timing of surgery, 5presence of amblyopia, associated ocular pathology,and greater severity of the diseased may significantlylimit visual outcome 4 .The upper age limit used to define the pediatricpopulation varies among experts and may includeadolescents up to the age of 21 which is consistentwith the definition foundin several well-knownsources 7,8 .The surgical procedure is technically morecomplex owing to the decreased rigidity and increasedelasticity of the infant cornea and sclera, the smallersize of the infant eye, the increased intraoperativefibrin formation and the positive vitreous pressure 4 .Postoperative follow up and management may bemore complicated, and graft rejection is often difficultto detect and treat 4 .MATERIAL AND METHODSThis retrospective case series reviewed 90 eyes of 85patients, who underwent penetrating keratoplasty72 Vol. 28, No. 2, Apr – Jun, 2012 Pakistan Journal of Ophthalmology

Munira Shakir, et al.from January 2006 to December 2008 in PediatricDepartment LRBT Free Base Eye Hospital, Karachi.Out of 85 patients, 45 (52.94%) were boys and 40Fig. 4:Fig. 1Fig. 2:(47.05%) were girls. Inclusion criteria includedpatients with age ranging from 6 to 14 years with nosex predeliction; patients diagnosed with traumaticcorneal scarring,corneal dystropies, keratoconus andhydrops, chemical injury and congenital glaucoma.Exclusion criteria included combined non-cornealprocedures,herpetic keratitis, patients with age below6 years and patients who were lost to followup.Minimum follow up was 6 months while meanfollow up was 15 months.Preoperatively all patientsunderwent a complete ocular examination whichincluded visual acuity assessment, intraocularpressure measurement, slit lamp and dilated fundusexamination, A and B scan if needed. At the end ofsurgery all patients received systemic and topicalsteroids to decrease inflammatory reaction. Topicalcycloplegics, steroids and antibiotic eye drops wereadministered postoperatively. Follow up examinationswere performed consisting of visual acuity assessmentand slit-lamp examination, intraocular pressure,fundus examination and if needed ultrasonicexaminations. In the eyes with amblyopia, occlusion oratropinization of the good eye was conductedpostoperatively. Early optical correction withspectacles or contact lenses was pursued asaggressively as possible.Data was analysed on SPSS (version 13).Frequency and percentages were calculated for age,gender, best corrected visual acuity, graft survival andfailure. Chi-square test and Fisher exact test wereapplied to calculate p-value and p< 0.005 was taken asstatistically significant.Fig. 3:SURGICAL TECHNIQUEAll penetrating keratoplasty surgeries were done bythe same surgeon, under general anesthesia. StandardPakistan Journal of Ophthalmology Vol. 28, No. 2, Apr – Jun, 2012 73

Corneal Graft in ChildrenTable 1: Graft failure and survival in different groups and their statistical significance (p

Munira Shakir, et al.for the poorer prognosis are technically difficultsurgery and irreversible amblyopia 9 .Penetrating keratoplasty in children is generallyconsidered a high risk procedure, because surgery in asmall eye can lead to a sclera collapse. Moreover, theiris is more adherent and the vitreous more tenaciousin children than in adults 9 . Improved results havebeen attributed in part to the advantages in surgicaltechnique, improved donor-storage media anddevelopment of viscoelastics. Therefore, the rate ofintraoperative complications has been significantlydeclined. 9 Despite all the developments, the incidenceof inflammatory reaction and immunological rejectionis still significant. The prognosis for graft clarity inchildren is poorer because of the high bioreactivityand healing potential of a child’s eye, which is veryrapid and causes sutures to loosen quickly 10 .In this series overall graft survival at the end offollow up was 65 out of 90 (72.22%). Graft performedfor keratoconus were most successful in terms of graftsurvival which was seen in 23 out of 26 (88.46%).Gabric N et all reported 64% graft survival in theirseries of corneal transplantation, with best prognosisin graft for keratoconus and congenital dystrophy 11 .Overall 5-year graft survival was 82%, withkeratoconus and corneal dystrophy as reported byRehman I et all 12 . Dandona L et al also reported 46.5%graft survival in their study, with highest rate of graftsurvival for keratoconus 13 . Patel HY, documented 82%graft survival at the end of one year 14 .In this study postoperative visual acuityimprovement was recorded in 64 out of 90 (71.11%)eyes. Visual acuity improvement ranged fromcounting finger to 6/12 partial. 22 out of 90 (24.44%)patients achieved a best corrected visual acuity of 6/24or better. McClellan et al reported improvement invisual acuity better than 6/60 in only 14% of cases 15 .Xu-Jia H et al reported improvement in visual acuityby 6/18 or better in 13% of cases 1 .CONCLUSIONIn this study 72.22% eyes showed clear cornea postoperativelywith improvement in visual acuity seen in71.11%. Most successful results were seen in eyes withkeratoconus in which graft survival was observed in88.46% cases. Keeping the above findings in view, weconclude that keratoplasy is a safe and effectivetreatment in pediatric age-group. Further clinical trialsare required to establish these findings.Author’s affiliationDr. Munira ShakirConsultant OphthalmologistL.R.B.T Free Base Eye Hospital, KarachiKorangi 2 1/2 , Karachi.Postal Code- 74900Dr. Syeda Aisha BokhariAssociate OphthalmologistL.R.B.T Free Base Eye Hospital, KarachiKorangi 2 1/2 , Karachi.Postal Code- 74900Dr. Shakir ZafarConsultant OphthalmologistL.R.B.T Free Base Eye Hospital, KarachiKorangi 2 1/2 , Karachi.Postal Code- 74900Dr. Zeeshan KamilAssociate OphthalmologistL.R.B.T Free Base Eye Hospital, KarachiKorangi 2 1/2 , KarachiPostal Code- 74900Dr. Syed Fawad RizviChief Consultant OphthalmologistL.R.B.T Free Base Eye Hospital, KarachiKorangi 21/2, KarachiPostal Code- 74900REFERENCE1. Xu HJ, Jiang XJ, Jie SM, et al. Pediatric penetratingkeratoplasty in shanghai: a retrospective multiple centre studyfrom 2003 to 2007. Chin Med J. 2008; 121: 1911-4.2. Corneal and refractive surgery. In: Kanski JJ. Clinicalophthalmology a systemic approach. London: ButterworthHeineman: 2011. 239-50.3. Mc Neill JI. Pentrating keratoplasty: preoperativeconsiderations, indications and outcomes. In Krachker JH,Mannis MJ, Holland EJ (eds). Mosby: Cornea, St Louis. 1997; 3:1551-61.4. Vajpayee RB, Ramu M, Panda A et al. Oversized grafts inchildren. Ophthalmology. 1999; 106: 829-32.5. Pediatric penentrating keratoplasty. In: Krachmer JH, MannisMJ, Holland EJ, Cornea: surgery of the cornea and conjunctiva.St Louis: Mosby Year Book. 1997; 1731-56.6. Leigh AG. Corneal grafting. Br J Clin Pract. 1958; 12: 329.7. Berham RE, Kliegman R, Arvin AM, et al. Nelson Textbook ofpediatrics, 15 th ed, Philadelphia: W.B Saunders company; 1996.8. Rudolph AM. Rudolph’s Pediatrics, 21 st Ed. NY: McGraw-Hill;2002.9. Stulting RD. Penetrating keratoplasty in children. In:Brightbill, F.S., (Ed.): Corneal surgery. (Mosby St. Louis,Missouri, 1993).10. Dana, MR, Schaumberg DA, Moyes AL, et al. Gomes JAP,Ophthalmology. 1997; 104: 1580.Pakistan Journal of Ophthalmology Vol. 28, No. 2, Apr – Jun, 2012 75

Corneal Graft in Children11. Gabric N, Dekaris I, Vojnikovic B, et al. Cornealtransplantation in children. Coll Antropol 2001; 25: 17-22.12. Rahman I, Carley F, Hillarby C, et al. Penetratingkeratoplasty: indications, outcomes, and complications. Eye.2009; 23: 1288-94.13. Dandona L, Naduvilath T, Janarthanan M, et al. Survivalanalysis and visual outcome in a large series of cornealtransplants in india.14. Patel HY, Ormonde S, Brookes NH, et al. The indications andoutcome of paediatric corneal transplantation in New Zealand:1991-2003. Br J Ophthalmol. 2005: 89: 404-8.15. McClellan K, Lai T, Grigg J, et al. Penetrating keratoplasty inchildren: visual and graft outcome. Br J Ophthalmol. 2003; 87:1212-4.76 Vol. 28, No. 2, Apr – Jun, 2012 Pakistan Journal of Ophthalmology