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Main Issues to Overcome in Modern Penetrating Keratoplasty

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Modern Keratoplasty

Part of the book series: Essentials in Ophthalmology ((ESSENTIALS))

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Abstract

We have provided a high-level overview that addresses two fundamental causes of early and late graft rejection (immunological rejection and endothelial cell failure) in the first section, as well as the short-term and long-term functional and refractive results of penetrating keratoplasty in the second.

The clinical features of graft failure following penetrating keratoplasty are discussed in greater depth in the third section. These clinical aspects cover prevention, therapy, safety measures, and methods for identifying corneal transplant rejection.

We also consider decreasing blood vessels in the recipient cornea and corneal angiogenesis. In the clinic, we should be cognizant of graft failure risk factors, including donor and eye banking protocols (age, sex, and graft size), besides recipient-related factors (primary diagnosis, number of surgeries, neovascularization, and comorbidities such as infections, glaucoma, ocular surface diseases, inflammation, and systemic chronic diseases).

In a couple of these subsections pertaining to Section 4, surgery-related aspects (combination treatments) and Penetrating keratoplasty in keratoconus were discussed (decentered grafts and suturing technique). The fourth and fifth sections address the postoperative care and management of astigmatism following penetrating keratoplasty, respectively. Subsections of the fifth section discuss postoperative intraocular pressure measurement and patient management to lower the likelihood of corneal transplant rejection. Immunosuppressive therapies (immunosuppressive, antiproliferative, blocking the activation and action of T cell, and induction of allospecific tolerance drugs) and Gene Therapy will be discussed alongside the role of various corticosteroids, their bioavailability, and duration in the treatment of corneal transplant rejection. Finally, we proved the use of several medications in eye clinics by considering KPs, vascularization, and iris adhesions to be the most common clinical points in the stages of acute corneal transplant rejection.

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Notes

  1. 1.

    If there are no risk factors, transplant rejection reduces as the recipient becomes older.

  2. 2.

    Considering size to prevent rejection.

  3. 3.

    The benefits of steroid treatment should be weighed against the risks of long-term steroid therapy, especially in those with an underlying condition that causes damage to the eyes.

  4. 4.

    Systemic sensitization to donor antigens is more likely than local alterations caused by the main graft to hasten the rejective reaction. This rejection is unrelated to MHC congruence and could be caused by MHC components shared by both the first and second donors. The survival of the second link will not be improved by matching the donor-recipient HLA17. Therefore, the chance of rejection increases after the second corneal transplant operation [99]. No increases in the chances of transplant rejection have been observed in the other eye of someone whose first eye has had a rejection corneal transplant in any of the authors’ clinical studies.

  5. 5.

    Immune reactions can occur after any inflammation in the eyes that have had corneal transplantation, and YAG laser capsulotomy is no exception. To decrease these immunological reactions, steroid drops should be used following capsulotomy [125, 126].

  6. 6.

    Topical steroid after Low-Risk surgery should be used for at least 2 months until ACAID is created, with eye pressure and lens position monitored regularly. In patients with a low risk of rejection, steroid treatment should be started at 2- to 3-h intervals and continued until the KP has entirely disappeared. Even daily use of a steroid drop can cause eye strain, cataracts in phakic patients, and corneal infectious crystalline keratopathy (ICK).

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Authors and Affiliations

  1. Translational Ophthalmology Research Center, Tehran University Medical Science, Tehran, Iran

    Farideh Doroodgar & Sana Niazi

  2. Negah Aref Ophthalmic Research Center, Shahid Beheshti University of Medical Science, Tehran, Iran

    Farideh Doroodgar

  3. Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran

    Sana Niazi & Hassan Hashemi

  4. Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Hassan Hashemi

  5. Department of Ophthalmology, Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Mohammad Ali Javadi

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  1. Farideh Doroodgar
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  2. Sana Niazi
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  3. Hassan Hashemi
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  4. Mohammad Ali Javadi
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Correspondence to Farideh Doroodgar .

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Editors and Affiliations

  1. Vissum Miranza, Miguel Hernández University, Alicante, Spain

    Jorge L. Alió

  2. Vissum-Instituto Oftalmologico de Alica, Miguel Hernandez University, Alicante, Alicante, Spain

    Jorge L. Alió del Barrio

Electronic Supplementary Material

Femtosecond-based keratoplasty (MP4 5468 kb)

Large graft in keratoconus to ensure the greatest fit (MP4 5026 kb)

Regraft in a high-risk case (MP4 8284 kb)

Penetrating Keratoplasty in a case with fungal infection (MP4 9190 kb)

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Doroodgar, F., Niazi, S., Hashemi, H., Javadi, M.A. (2023). Main Issues to Overcome in Modern Penetrating Keratoplasty. In: Alió, J.L., del Barrio, J.L.A. (eds) Modern Keratoplasty. Essentials in Ophthalmology. Springer, Cham. https://doi.org/10.1007/978-3-031-32408-6_5

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