Changing times for pediatric keratoplasty

Update on Pediatric Corneal Diseases and Keratoplasty

Managing pediatric corneal disorders is challenging as the prognosis of pediatric keratoplasty depends on several factors. Advancements in the genetic basis of congenital corneal diseases and investigations in congenital corneal conditions provide a better understanding of pediatric corneal conditions. Surgeons performing keratoplasty in children now have a choice of various techniques. Evolving surgical techniques of anterior lamellar and endothelial keratoplasties has expanded the management interventions in these pediatric corneal morbidity conditions; however, considerable concerns still exist in association with corneal transplantation in infants and children. Outcomes in pediatric keratoplasty depend upon the preoperative indications, the timing of surgical intervention, intraoperative and postoperative factors including the patient/care givers' compliance. Factors such as low scleral rigidity, higher rate of graft failure, need for frequent examinations under anesthesia, and difficulty in optimal visual acuity assessment still remain a considerable challenge in pediatric scenarios. In children, deprivation amblyopia as a result of the corneal opacification can adversely affect visual development, causing dense amblyopia. Outcomes to surgical interventions for management of corneal opacification in children is further compromised by the pre-existing amblyopia apart from the concerns of refractive outcome of the graft. Graft rejection, graft infection, amblyopia, and glaucoma continue to be serious concerns. In recent years both anterior and posterior lamellar keratoplasty techniques are being increasingly performed in pediatric eyes, which offer advantages in the form of lower risk of graft rejection. The timing of surgery, careful case selection, cautious intraoperative approach, and optimal postoperative management can improve the anatomical and functional outcome in difficult cases.

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.

Indications and Outcomes of Penetrating Keratoplasty in Infants and Children of Beijing, China

PURPOSE

To retrospectively investigate the indications and outcomes of pediatric penetrating keratoplasty (PKP) and to explore factors that affect graft survival.

METHODS

Patients who had undergone PKP from May 2010 to December 2016, aged ≤12 years were categorized as infants (≥3 months and <4 years) or children (≥4 years and ≤12 years). Clinical data including patient demographics, indications, surgical procedures, postoperative follow-up, and graft clarity were recorded and analyzed.

RESULTS

Among 160 eyes of 146 patients, 79 eyes and 81 eyes were treated from the infant and child groups, respectively, and followed up for 33.7 ± 21.7 months (range, 6 months to 7 years). The most common indication for PKP was congenital corneal opacity (71.9%). The survival rate of all corneal grafts was 68.1%. The rejection reaction rate was 33.8%. More children than infants underwent PKP that was combined with other intraocular surgeries (P < 0.05). The graft failures were in the regraft (52.0%), congenital opacities (30.4%), and acquired opacities (15.0%) groups. The rate of graft failure in patients who received PKP combined with other intraocular surgery (40.0%) was higher than those who received PKP only (30.0%). The univariate logistic regression analysis revealed that the graft failure was associated with the graft indication (P < 0.05).

CONCLUSIONS

The most common indication for PKP in children younger than 12 years was congenital corneal opacity in Beijing, China. The graft survival was 68.1%, with a mean follow-up of 33.7 months. Graft failure was associated with the indication.

Indications and outcomes of pediatric keratoplasty in a tertiary eye care center: A retrospective review

To evaluate indications and outcomes of pediatric keratoplasty in a tertiary eye center, and identify factors that affect visual outcomes.We performed a retrospective review of penetrating keratoplasty in children aged 0 to 18 years between 1995 and 2011 in the Asociación para Evitar la Ceguera en México IAP, Hospital "Dr. Luis Sánchez Bulnes".A total of 574 penetrating keratoplasties were performed during the study interval. Median follow-up was 5.0 years. Main indications included keratoconus (55.58%), postherpetic scarring (9.58%), traumatic opacities (7.49%), and bullous keratopathy (6.09%). Rejection rates at 5 years were 27% overall, and among indications, keratoconus showed the best graft survival at 60-months follow-up (85%). The percentage of patients with best corrected visual acuity (BCVA) posttransplant >20/400 at 5 years in the nonrejection group was 81.25% and 82.74% in < and > 10 years of age (YOA) groups, respectively, versus a BCVA posttransplant > 20/400 at 5 years in the rejection group of 53.68% and 51.72% in < and > 10 YOA groups, respectively. There was a statistically significant reduced rejection rate between genders at 18 months of follow-up, favoring males.Despite being considered a high-risk procedure in children, penetrating keratoplasty can achieve good results, especially in patients with keratoconus. It can achieve significative improvements of visual acuity, provided there is an adequate follow-up and treatment adherence.

Four years of corneal keratoplasty in Italian paediatric patients: indications and clinical outcomes

PURPOSE

The purpose was to evaluate indications and clinical outcomes in paediatric corneal keratoplasty.

METHODS

Fifty-four eyes of 43 patients who underwent corneal keratoplasty from the 1^st of January 2010 through the 31^st of December 2013 at the Bambino Gesù Children's Hospital in Rome, Italy, were retrospectively evaluated. To assess the effect of age on graft failure rate, the recipient age was considered as a dichotomous variable (≤5 or >5 years) and a 2X2 table was developed, using the chi-square test for testing the statistical significance. Furthermore, two separate subgroup analyses were conducted on patients of ≤5 years and those of >5 years, to evaluate the effect of penetrating keratoplasty (PK) or deep anterior lamellar keratoplasty (DALK) on the graft failure rate. The level of statistical significance was set at p < 0.05 RESULTS: Mean recipient age was 8.9 ± 5.7 [SD] years. Mean follow-up time was 22.8 months. Main preoperative diagnoses were keratoconus (37 %) and congenital glaucoma (20 %). Patients ≤5 years showed a higher percentage of graft failure (p = 0.0008). PK and DALK did not show statistically significant differences regarding the graft failure in both subgroups (p = 0.15 for ≤5 years group and p = 0.27 for >5 years group, respectively). However, across groups DALK provided a lower rate of graft failure.

CONCLUSIONS

Our findings suggest that children older than 5 years show a significantly better graft outcome and that DALK seems to offer greatest benefits in terms of failure risk in paediatric patients.

Descemet stripping automated endothelial keratoplasty in a child after failed penetrating keratoplasty

Use of Descemet stripping automated endothelial keratoplasty (DSAEK) has been reported in children for the treatment of postoperative endothelial decompensation and Descemet membrane break after forceps delivery. Rapid visual recovery and minimally induced postoperative astigmatism make DSAEK preferable to penetrating keratoplasty for the management of isolated endothelial disorders in this age group. We present a case of DSAEK in a 4-year-old boy for the management of irreversible endothelial rejection after penetrating keratoplasty. Three months after the procedure, the cornea remained clear with the donor button in place.

Early outcomes of primary pediatric keratoplasty in patients with acquired, atraumatic corneal pathology

PURPOSE

To evaluate the early outcomes of pediatric corneal transplantation in patients with acquired, nontraumatic corneal pathology.

METHODS

In this retrospective series, the records of children 15 years of age or younger who underwent optical penetrating keratoplasty for acquired nontraumatic corneal pathologies between December 2008 and June 2010 were reviewed. Demographic features, etiology of opacification, visual acuity, and other clinical findings were recorded.

RESULTS

Nineteen eyes of 19 children (10 females) were included. Mean age at time of surgery was 9.1 ± 3.01 years (range, 5-15 years). Adherent leukoma secondary to healed infectious keratitis (n = 12, 63%) and keratoconus (n = 7, 37%) were the leading indications for surgery. The mean follow-up period was 10.2 ± 3.3 months (range, 6-18 months). Postoperatively, clear grafts were seen in 15 cases (79%). Graft failure was noted in 4 eyes secondary to allograft rejection (n = 1), graft infection (n = 1), primary graft failure (n = 1), and uncontrolled glaucoma (n = 1). The most common cause of moderate or poor visual outcome was amblyopia (80%). Overall, 13 patients (68%) had postoperative visual acuity better than the preoperative vision.

CONCLUSIONS

Penetrating keratoplasty can yield good anatomic results in children with acquired, nontraumatic causes of corneal scarring, but amblyopia limits the visual outcomes.