Pediatric Corneal Transplantation—Where Are We Heading?

Outcomes of Corneal Transplantation After Minimally Invasive Corneal Neurotization in Children

PURPOSE

To describe the outcomes of corneal transplantation after minimally invasive corneal neurotization (MICN) in pediatric patients.

METHODS

Medical records of all children who underwent corneal transplantation post-MICN with sural nerve graft for neurotrophic keratopathy between 2015 and 2021 were reviewed retrospectively. Data collected included demographic information, ocular comorbidities, maximum corneal sensitivity by Cochet-Bonnet aesthesiometer (CBA) preoperatively and postoperatively measured in the central graft area, graft survival (primary outcome), and rejection.

RESULTS

Of 28 eyes which underwent MICN, six underwent corneal transplant surgery (mean age 11.9 ± 4.4 years) 2.4 ± 0.4 years after initial surgery. Mean maximum recorded CBA across all quadrants before corneal transplantation was 53.3 ± 9.4 mm. Reepithelialization was observed in all eyes by postoperative month 2. Mean follow-up was 4.5 ± 2.1 years. Penetrating keratoplasty was performed in 2 cases, and deep anterior keratoplasty in four cases. Graft survival at final follow-up was 83.3%. Mean recorded central CBA after corneal transplantation was 53.8 ± 8.2 mm. No improvement was observed in visual acuity from baseline (1.2 ± 0.4 logMAR) to final postoperative follow-up (1.1 ± 0.4 logMAR; P = 0.68).

CONCLUSIONS

Corneal transplantation after corneal neurotization has survival rates >80%. Manual deep anterior keratoplasty can be performed in patients who have not undergone previous penetrating keratoplasty. Despite graft clarity, improvement in best-corrected visual acuity may be limited by amblyopia in this age group.

Pediatric endothelial keratoplasty: a systematic review and individual participant data meta-analysis

BACKGROUND

Recently, endothelial keratoplasty (EK) has been increasingly considered the first intervention in pediatrics with isolated corneal endothelial dysfunction. This systematic review aims to investigate the current evidence about the advantages, disadvantages, technical challenges, and clinical outcomes of EK in the pediatric group.

METHOD

All the English literature relevant to pediatric EK was searched in PubMed, Embase, Scopus, and Cochrane databases with appropriate keywords. Relevant data were pooled to conduct an individual participant data meta-analysis.

RESULTS

Of 1646 articles found initially, 35 articles were finally eligible to be included in our study. A total of 154 eyes of 107 patients underwent Descemet's stripping automated endothelial keratoplasty (DSAEK). Congenital hereditary endothelial dystrophy (CHED) was the most reported indication for pediatric DSAEK (108 eyes). Descemet's membrane endothelial keratoplasty (DMEK) was performed in 2 eyes of 2 cases, one with PPCD and another one in a patient with Kearns-Sayre syndrome. Owing to some specific anatomical and physiological pediatric characteristics, some modifications in a standard procedure were suggested. The average follow-up period was 23.80 ± 20.18 months (3 months to 8.5 years). Seventy-six eyes who had a mean best-corrected visual acuity (BCVA) of 1.36 ± 0.70 (0.49 to 3) logMAR preoperatively found mean BCVA of 0.51 ± 0.33 (0.04 to 2) logMAR postoperatively. Graft dislocation was the most reported complication (26 eyes). The rate of other complications was low. Endothelial cell loss was reported from 8.3 to 63.7% after pediatric EK with follow-up duration from 3 months to 8.3 years.

CONCLUSION

EK procedures, despite some technical challenges, are feasible surgical techniques with acceptable visual and anatomical outcomes in the management of pediatrics with corneal endothelial dysfunction and minimal stromal involvement.

Visual Outcomes and Complications of Type I Boston Keratoprosthesis in Children: A Retrospective Multicenter Study and Literature Review

PURPOSE

To report outcomes and complications of Boston type 1 keratoprosthesis (KPro) implantation in children.

DESIGN

Retrospective, multicenter case series.

PARTICIPANTS

All children 16 years of age or younger who underwent KPro surgery at 3 ophthalmology centers in Canada between January 2010 and November 2014.

METHODS

Records of patients having undergone KPro implantation were reviewed. Data on preoperative characteristics, surgical procedure(s) performed, and postoperative outcomes were collected and analyzed.

MAIN OUTCOME MEASURES

Intraoperative and postoperative complications, device retention, and best-corrected visual acuity (BCVA).

RESULTS

The KPro was implanted in 11 eyes of 11 patients 0.9 to 15.5 years of age, with 6 being primary corneal procedures. Best-corrected visual acuity recorded before surgery ranged from 20/600 to light perception (LP), and vision in 2 eyes was fix and follow. All patients had been diagnosed with glaucoma and 6 eyes had glaucoma drainage devices (GDDs) inserted before KPro implantation. At last follow-up (mean, 41.8 months; range, 6.5-85.0 months), 2 eyes retained BCVA of 20/400 or better, whereas 5 eyes lost LP. Postoperative complications included retroprosthetic membrane (9 eyes), corneal melt (5 eyes), infectious keratitis (3 eyes), endophthalmitis (3 eyes), GDD erosion (2 eyes), and retinal detachment (5 eyes). The initial KPro was retained in 4 eyes (36.4%).

CONCLUSIONS

Boston type 1 keratoprosthesis implantation in children is associated with a substantially higher rate of complications, higher chance of device failure, and worse visual outcomes than observed in adults. In view of these results, the authors do not recommend the use of the KPro in the pediatric population.