Early Repeated Bartly J. Mondino, MD, Stuart I. Brown,
MD
\s=b\ Case reports are presented of four corneal grafts that were replaced 7 to 26 days after the initial surgery. The reasons for regrafting were incomplete epithelialization of the donor cornea by the host, poor donor material, and ring synechiae with secondary glaucoma. All regrafts in these cases have remained transparent. The advantages of early regrafting include earlier visual rehabilitation, avoidance of host corneal vascularization, and prevention of fibrotic organization of synechiae when present. Despite the prevalent notion that early corneal regrafting is inadvisable, when faced with a corneal graft that has little chance of success and then only with prolonged and intensive treatment, we believe that early regrafting may be advisable.
(Arch Ophthalmol 94:1720-1722, 1976)
has been recommended that one wait six months after a failed corneal transplant before repeating the procedure.' This is the only refer¬ ence to the optimum time before regrafting known to the authors in the past 25 years. Because this approach had general acceptance, Bar¬ raquera report of a successful corneal regraft three weeks after the initial transplant was unique.- He stated that an early regraft may avoid host corneal vascularization. The present
It
Accepted
for publication March 26, 1976. From the Department of Ophthalmology, University of Pittsburgh School of Medicine and Eye and Ear Hospital. Reprint requests to Department of Ophthalmology, Eye and Ear Hospital, 230 Lothrop St,
Pittsburgh,
PA 15213
(Dr Brown).
Corneal Grafts report describes successful corneal
regrafts 7 to 26 days postoperatively and suggests indications for them. Clinical Data Four of the last 150 corneal transplants performed by one of the authors (S.I.B.) underwent a second corneal graft 7 to 26 days after initial surgery.
REPORT OF CASES Case 1.—A 72-year-old woman, examined in February 1973, was found to have a visual acuity of 20/50 in the right eye (OD) and finger counting at 1 ft in the left eye (OS). The right eye was essentially normal, except for nuclear sclerosis of the crystalline lens, which was judged to be compatible with the 20/50 visual acuity. Her left eye had aphakic, bullous keratopa¬ thy, which developed soon after a cataract extraction two years prior to the examina¬ tion. On April 5, 1973, she underwent a penetrating keratoplasty of the left eye. The donor cornea was enucleated two hours after death and was used within 18 hours of the donor's death. The donor was 56 years of age. During surgery, numerous anterior synechiae were lysed and retrocor¬ neal fibrous tissue was excised, as were large remnants of both lens capsule and cortex. The first day postoperatively, it was noted that the corneal transplant was swollen to at least twice its normal thick¬ ness (Fig 1). The patient was treated with hourly topical dexamethasone 0.1% (Maxidex), daily oral prednisone in a dosage of 60 mg, and an injection below the Tenon capsule of 40 mg of triamcinolone diacetate (Aristocort). Nevertheless, the corneal graft continued to swell over the next six days. Since the patient was solely respon¬ sible for the care of her sick husband, she
Downloaded From: http://archopht.jamanetwork.com/ by a University of Iowa User on 06/19/2015
reluctant to continue hospitalization for any extended period of time. Because the patient lived more than 100 miles from the hospital, and would not be able to make frequent postoperative visits, and because the surgeon believed that there was only a small chance for the graft to improve, a regraft was performed on the seventh postoperative day. The procedure was rather simple, since once the sutures were cut the graft was pulled from the host bed and a new graft was sutured in place. Triamcinolone diacetate (Aristocort) was injected subconjunctivally before the pa¬ tient left the operating room. Postopera¬ tively, the graft remained transparent with only topical dexamethasone 0.1% and the patient was able to be discharged from the hospital on the fourth postoperative day. This graft has remained transparent for more than one year (Fig 2). Histopathologic examination of the failed corneal transplant revealed only a single layer of epithelium, many guttas, and no endothelium (Fig 3). The early graft failure in this case was attributed to poor donor material. Case 2.—A 51-year-old man underwent a corneal transplant and cataract extraction on May 14, 1973, because of keratoconus and cataract in his left eye. The donor cornea was obtained from a 28-year-old patient five hours after death and used three hours later. At surgery, the iris could not be separated from the back of the cornea when the anterior chamber was reformed. Immediately after the opera¬ tion, the iris was attached to the wound for nearly 270 degrees. During the week after surgery, the iris attachment increased to involve the entire circumference of the wound. The chamber depth was relatively normal with an intact vitreous face, but the intraocular pressure became elevated bewas
Fig 1.—Prominently tively.
edematous corneal
graft
of the extensive anterior synechiae and could only be controlled with 75 ml of oral glycerin (Glyrol) given four times a day. There was epithelial edema but no gross stromal thickening. The patient was referred to one of the authors, and on June 17, 1973, the corneal transplant was repeated. At surgery, the donor cornea was pulled from the recipient bed, the iris was separated from the back of the cornea with an iris spatula, and an anterior vitrectomy was performed. Two peripheral iridotomies were made at 3- and 9 o'clock position, facing the patient. In addition, radial iri¬ dotomies were made on each side of the one area where the iris could not be freed from the back of the cornea. The iris was observed to fall back into the posterior chamber and a fresh donor cornea was sutured in place. Postoperatively, the graft remained transparent with only topical corticosteroid medications. The intraocular tension was elevated, but was controlled to within normal levels with acetazolamide (Diamox) and pilocarpine hydrochloride 4% (Pilocar). The corneal transplant remained clear for one year postoperatively and thereafter, the patient was lost to follow up examinations. In this case, the decision for an early regraft was prompted by the uncontrol¬ lable intraocular tension resulting from the anterior synechiae. Lysis of such extensive synechiae without regrafting was not attempted, since it would have resulted in the destruction of the donor corneal endo¬ thelium. Removal of the first graft provided adequate access for lysis of syne¬ chiae. This graft was replaced with fresh donor material to insure a functioning endothelium. Case 3.-A 58-year-old woman had a visual acuity of 20/20 in her right eye and cause
six
days postopera¬
Fig 2.—Regraft of same cornea as in Fig months postoperatively.
Fig 3.—Original corneal graft in patient 1 with absence (hematoxylin-eosin, original magnification 450).
finger counting at 1 ft because of aphakic, bullous keratopathy in her left eye. The patient was a butcher and was anxious to have binocular vision. A corneal transplant was performed on Jan 5, 1974, using a cornea from a 60-year-old donor. The donor eye was enucleated two hours after death and used within 24 hours. During the trans¬
the epithelium was removed from the donor cornea. Postopera¬ tively, the host epithelium advanced over only one-half of the surface of the donor cornea and stopped. Treatment with pres¬ sure patching, followed by use of soft contact lenses, did not result in further advancement of the host epithelium. The
plant procedure,
Downloaded From: http://archopht.jamanetwork.com/ by a University of Iowa User on 06/19/2015
graft
1. Graft is
transparent 11
of endothelium and
early guttas
became grossly edematous where there was no epithelium, while the epithelialized portion of the graft was transpar¬ ent. The conjunctival vessels were dilated and a moderate anterior chamber reaction was apparent. It was elected to perform a regraft of this eye on Jan 31 because of failure of epithelialization of the donor cornea and the resultant stromal edema in the area of the epithelial defect. In the latter procedure, the donor epithelium was left on the donor cornea. Postoperatively, the donor epithelium remained on the donor cornea, which remained transparent with only topical dexamethasone 0.1%. The patient returned to her home in another
state and
physician.
was followed up by her local Her corneal graft has remained
transparent. In this patient, the problem involved incomplete epithelialization of the graft. In the epithelialized portion, the graft was thin and transparent and the epithelium was not edematous. In the nonepithelialized portion, the stroma was thick and edematous. Complete epithelialization of the donor cornea was not achieved in spite of three weeks of treatment. A persistent epithelial defect of this size would even¬ tually result in corneal opacification and delayed wound healing. Because of eco¬ nomic and practical considerations involv¬ ing the patient, and because the surgeon believed there was little chance of epithe¬ lialization without further prolonged treat¬ ment and frequent examinations, it was elected to repeat the graft, using a donor graft with the epithelium left in place. Case 4.—A 51-year-old woman had a history of lattice dystrophy with a visual acuity of 20/800 in both eyes for 15 years. She elected to have a corneal transplant on her left eye on April 18, 1974. The donor cornea was obtained from a 57-year-old patient six hours after death and was grafted two hours later. During the proce¬ dure, the epithelium was removed from the donor cornea. Postoperatively, the graft
transparent, but there was consid¬ erable dilation of the conjunctival vessels, a moderate anterior chamber inflammatory response and, in addition, the host epithe¬ lium did not completely heal over the surface of this graft. The patient was treated with various medications, debride¬ ment, pressure patching, and a soft contact lens to aid epithelialization. The epithelium did not heal, the inflammation continued, and the graft became edematous in the area where the epithelium was absent. On May 11, three weeks postoperatively, another corneal transplant with the epithe¬ lium left on the donor cornea was performed. Postoperatively, the eye was was
immediately free of inflammation, the epithelium was intact, and the graft remained transparent for the past two years. In this case, there was a failure of epithelialization of the donor graft by the
recipient epithelium. Attempts to promote epithelialization of the donor cornea were unsuccessful and the graft was repeated. COMMENT The four patients described in this series all had second corneal trans¬ plants within one month of their orig¬ inal surgery. The reasons for regraft¬ ing were as follows: suspected and later confirmed poor donor material in the first patient, uncontrollable in¬ traocular tensions caused by extensive anterior synechiae in the second pa¬ tient, and incomplete healing of the corneal epithelium in the third and fourth patients. In every instance, the second procedure was quick and un¬
complicated.
considered after the initial procedures that all of the grafts with the exception of the one with exten¬ sive anterior synechiae might have been retrievable with further pro¬ longed and vigorous treatment. How¬ ever, it was thought that early re¬ grafting offered a better chance for a transparent graft and for early visual rehabilitation. Early visual rehabilita¬ tion was particularly important to the patients in this series since they had responsibilities that precluded It
was
lengthy hospitalization. The indication for regrafting in the last two patients was slow-healing host epithelium. This is a definite complication of corneal transplanta¬ tion, which has been rarely described. In the majority of cases, slow-healing
Downloaded From: http://archopht.jamanetwork.com/ by a University of Iowa User on 06/19/2015
will cover a corneal had its epithelium that has graft removed during transplantation, es¬ pecially after treatment with the soft contact lens. In the rare case in which the epithelium fails to heal, the stroma of the corneal graft under¬ lying the epithelial defect may opacify and vascularize. In addition, when the epithelial defect involves the kerato¬ plasty wound, poor wound healing may results In the authors' experi¬ ence, failure of epithelialization of the graft occurs most frequently in eyes with lattice corneal dystrophy, re¬ duced tear volume, herpes simplex keratitis, and alkali burns. Because of this, the authors take care to include the donor epithelium on all donor corneas used for these conditions. In the past, the basis for avoiding retransplantation until six months postoperatively was probably the fear that earlier surgery might promote inflammation. However, in all eyes inflammation was quickly controlled with corticosteroids. The advantages of early surgery are obvious, ie, earlier visual rehabilitation of the eye, syne¬ chiae do not become fibrosed and, as Barraquer stated, host corneal vascu¬ larization is avoided.-'
host
epithelium
References RP, and Kalevar V: Regrafting. Int Clin 12:292, 1972. 2. Barraquer, J.: Le traitement chirurgical de l'oedeme et de l'opacification du greffon. Arch Ophthalmol 27:831-838, 1967. 3. Dohlman CH: The function of the corneal epithelium in health and disease. Invest Ophthalmol 10:383-407, 1971. 4. Gasset AR, Dohlman CH: The tensile strength of corneal wounds. Arch Ophthalmol 79:595-602, 1968. 1. Dhanda
Ophthalmol
MD
\s=b\ Case reports are presented of four corneal grafts that were replaced 7 to 26 days after the initial surgery. The reasons for regrafting were incomplete epithelialization of the donor cornea by the host, poor donor material, and ring synechiae with secondary glaucoma. All regrafts in these cases have remained transparent. The advantages of early regrafting include earlier visual rehabilitation, avoidance of host corneal vascularization, and prevention of fibrotic organization of synechiae when present. Despite the prevalent notion that early corneal regrafting is inadvisable, when faced with a corneal graft that has little chance of success and then only with prolonged and intensive treatment, we believe that early regrafting may be advisable.
(Arch Ophthalmol 94:1720-1722, 1976)
has been recommended that one wait six months after a failed corneal transplant before repeating the procedure.' This is the only refer¬ ence to the optimum time before regrafting known to the authors in the past 25 years. Because this approach had general acceptance, Bar¬ raquera report of a successful corneal regraft three weeks after the initial transplant was unique.- He stated that an early regraft may avoid host corneal vascularization. The present
It
Accepted
for publication March 26, 1976. From the Department of Ophthalmology, University of Pittsburgh School of Medicine and Eye and Ear Hospital. Reprint requests to Department of Ophthalmology, Eye and Ear Hospital, 230 Lothrop St,
Pittsburgh,
PA 15213
(Dr Brown).
Corneal Grafts report describes successful corneal
regrafts 7 to 26 days postoperatively and suggests indications for them. Clinical Data Four of the last 150 corneal transplants performed by one of the authors (S.I.B.) underwent a second corneal graft 7 to 26 days after initial surgery.
REPORT OF CASES Case 1.—A 72-year-old woman, examined in February 1973, was found to have a visual acuity of 20/50 in the right eye (OD) and finger counting at 1 ft in the left eye (OS). The right eye was essentially normal, except for nuclear sclerosis of the crystalline lens, which was judged to be compatible with the 20/50 visual acuity. Her left eye had aphakic, bullous keratopa¬ thy, which developed soon after a cataract extraction two years prior to the examina¬ tion. On April 5, 1973, she underwent a penetrating keratoplasty of the left eye. The donor cornea was enucleated two hours after death and was used within 18 hours of the donor's death. The donor was 56 years of age. During surgery, numerous anterior synechiae were lysed and retrocor¬ neal fibrous tissue was excised, as were large remnants of both lens capsule and cortex. The first day postoperatively, it was noted that the corneal transplant was swollen to at least twice its normal thick¬ ness (Fig 1). The patient was treated with hourly topical dexamethasone 0.1% (Maxidex), daily oral prednisone in a dosage of 60 mg, and an injection below the Tenon capsule of 40 mg of triamcinolone diacetate (Aristocort). Nevertheless, the corneal graft continued to swell over the next six days. Since the patient was solely respon¬ sible for the care of her sick husband, she
Downloaded From: http://archopht.jamanetwork.com/ by a University of Iowa User on 06/19/2015
reluctant to continue hospitalization for any extended period of time. Because the patient lived more than 100 miles from the hospital, and would not be able to make frequent postoperative visits, and because the surgeon believed that there was only a small chance for the graft to improve, a regraft was performed on the seventh postoperative day. The procedure was rather simple, since once the sutures were cut the graft was pulled from the host bed and a new graft was sutured in place. Triamcinolone diacetate (Aristocort) was injected subconjunctivally before the pa¬ tient left the operating room. Postopera¬ tively, the graft remained transparent with only topical dexamethasone 0.1% and the patient was able to be discharged from the hospital on the fourth postoperative day. This graft has remained transparent for more than one year (Fig 2). Histopathologic examination of the failed corneal transplant revealed only a single layer of epithelium, many guttas, and no endothelium (Fig 3). The early graft failure in this case was attributed to poor donor material. Case 2.—A 51-year-old man underwent a corneal transplant and cataract extraction on May 14, 1973, because of keratoconus and cataract in his left eye. The donor cornea was obtained from a 28-year-old patient five hours after death and used three hours later. At surgery, the iris could not be separated from the back of the cornea when the anterior chamber was reformed. Immediately after the opera¬ tion, the iris was attached to the wound for nearly 270 degrees. During the week after surgery, the iris attachment increased to involve the entire circumference of the wound. The chamber depth was relatively normal with an intact vitreous face, but the intraocular pressure became elevated bewas
Fig 1.—Prominently tively.
edematous corneal
graft
of the extensive anterior synechiae and could only be controlled with 75 ml of oral glycerin (Glyrol) given four times a day. There was epithelial edema but no gross stromal thickening. The patient was referred to one of the authors, and on June 17, 1973, the corneal transplant was repeated. At surgery, the donor cornea was pulled from the recipient bed, the iris was separated from the back of the cornea with an iris spatula, and an anterior vitrectomy was performed. Two peripheral iridotomies were made at 3- and 9 o'clock position, facing the patient. In addition, radial iri¬ dotomies were made on each side of the one area where the iris could not be freed from the back of the cornea. The iris was observed to fall back into the posterior chamber and a fresh donor cornea was sutured in place. Postoperatively, the graft remained transparent with only topical corticosteroid medications. The intraocular tension was elevated, but was controlled to within normal levels with acetazolamide (Diamox) and pilocarpine hydrochloride 4% (Pilocar). The corneal transplant remained clear for one year postoperatively and thereafter, the patient was lost to follow up examinations. In this case, the decision for an early regraft was prompted by the uncontrol¬ lable intraocular tension resulting from the anterior synechiae. Lysis of such extensive synechiae without regrafting was not attempted, since it would have resulted in the destruction of the donor corneal endo¬ thelium. Removal of the first graft provided adequate access for lysis of syne¬ chiae. This graft was replaced with fresh donor material to insure a functioning endothelium. Case 3.-A 58-year-old woman had a visual acuity of 20/20 in her right eye and cause
six
days postopera¬
Fig 2.—Regraft of same cornea as in Fig months postoperatively.
Fig 3.—Original corneal graft in patient 1 with absence (hematoxylin-eosin, original magnification 450).
finger counting at 1 ft because of aphakic, bullous keratopathy in her left eye. The patient was a butcher and was anxious to have binocular vision. A corneal transplant was performed on Jan 5, 1974, using a cornea from a 60-year-old donor. The donor eye was enucleated two hours after death and used within 24 hours. During the trans¬
the epithelium was removed from the donor cornea. Postopera¬ tively, the host epithelium advanced over only one-half of the surface of the donor cornea and stopped. Treatment with pres¬ sure patching, followed by use of soft contact lenses, did not result in further advancement of the host epithelium. The
plant procedure,
Downloaded From: http://archopht.jamanetwork.com/ by a University of Iowa User on 06/19/2015
graft
1. Graft is
transparent 11
of endothelium and
early guttas
became grossly edematous where there was no epithelium, while the epithelialized portion of the graft was transpar¬ ent. The conjunctival vessels were dilated and a moderate anterior chamber reaction was apparent. It was elected to perform a regraft of this eye on Jan 31 because of failure of epithelialization of the donor cornea and the resultant stromal edema in the area of the epithelial defect. In the latter procedure, the donor epithelium was left on the donor cornea. Postoperatively, the donor epithelium remained on the donor cornea, which remained transparent with only topical dexamethasone 0.1%. The patient returned to her home in another
state and
physician.
was followed up by her local Her corneal graft has remained
transparent. In this patient, the problem involved incomplete epithelialization of the graft. In the epithelialized portion, the graft was thin and transparent and the epithelium was not edematous. In the nonepithelialized portion, the stroma was thick and edematous. Complete epithelialization of the donor cornea was not achieved in spite of three weeks of treatment. A persistent epithelial defect of this size would even¬ tually result in corneal opacification and delayed wound healing. Because of eco¬ nomic and practical considerations involv¬ ing the patient, and because the surgeon believed there was little chance of epithe¬ lialization without further prolonged treat¬ ment and frequent examinations, it was elected to repeat the graft, using a donor graft with the epithelium left in place. Case 4.—A 51-year-old woman had a history of lattice dystrophy with a visual acuity of 20/800 in both eyes for 15 years. She elected to have a corneal transplant on her left eye on April 18, 1974. The donor cornea was obtained from a 57-year-old patient six hours after death and was grafted two hours later. During the proce¬ dure, the epithelium was removed from the donor cornea. Postoperatively, the graft
transparent, but there was consid¬ erable dilation of the conjunctival vessels, a moderate anterior chamber inflammatory response and, in addition, the host epithe¬ lium did not completely heal over the surface of this graft. The patient was treated with various medications, debride¬ ment, pressure patching, and a soft contact lens to aid epithelialization. The epithelium did not heal, the inflammation continued, and the graft became edematous in the area where the epithelium was absent. On May 11, three weeks postoperatively, another corneal transplant with the epithe¬ lium left on the donor cornea was performed. Postoperatively, the eye was was
immediately free of inflammation, the epithelium was intact, and the graft remained transparent for the past two years. In this case, there was a failure of epithelialization of the donor graft by the
recipient epithelium. Attempts to promote epithelialization of the donor cornea were unsuccessful and the graft was repeated. COMMENT The four patients described in this series all had second corneal trans¬ plants within one month of their orig¬ inal surgery. The reasons for regraft¬ ing were as follows: suspected and later confirmed poor donor material in the first patient, uncontrollable in¬ traocular tensions caused by extensive anterior synechiae in the second pa¬ tient, and incomplete healing of the corneal epithelium in the third and fourth patients. In every instance, the second procedure was quick and un¬
complicated.
considered after the initial procedures that all of the grafts with the exception of the one with exten¬ sive anterior synechiae might have been retrievable with further pro¬ longed and vigorous treatment. How¬ ever, it was thought that early re¬ grafting offered a better chance for a transparent graft and for early visual rehabilitation. Early visual rehabilita¬ tion was particularly important to the patients in this series since they had responsibilities that precluded It
was
lengthy hospitalization. The indication for regrafting in the last two patients was slow-healing host epithelium. This is a definite complication of corneal transplanta¬ tion, which has been rarely described. In the majority of cases, slow-healing
Downloaded From: http://archopht.jamanetwork.com/ by a University of Iowa User on 06/19/2015
will cover a corneal had its epithelium that has graft removed during transplantation, es¬ pecially after treatment with the soft contact lens. In the rare case in which the epithelium fails to heal, the stroma of the corneal graft under¬ lying the epithelial defect may opacify and vascularize. In addition, when the epithelial defect involves the kerato¬ plasty wound, poor wound healing may results In the authors' experi¬ ence, failure of epithelialization of the graft occurs most frequently in eyes with lattice corneal dystrophy, re¬ duced tear volume, herpes simplex keratitis, and alkali burns. Because of this, the authors take care to include the donor epithelium on all donor corneas used for these conditions. In the past, the basis for avoiding retransplantation until six months postoperatively was probably the fear that earlier surgery might promote inflammation. However, in all eyes inflammation was quickly controlled with corticosteroids. The advantages of early surgery are obvious, ie, earlier visual rehabilitation of the eye, syne¬ chiae do not become fibrosed and, as Barraquer stated, host corneal vascu¬ larization is avoided.-'
host
epithelium
References RP, and Kalevar V: Regrafting. Int Clin 12:292, 1972. 2. Barraquer, J.: Le traitement chirurgical de l'oedeme et de l'opacification du greffon. Arch Ophthalmol 27:831-838, 1967. 3. Dohlman CH: The function of the corneal epithelium in health and disease. Invest Ophthalmol 10:383-407, 1971. 4. Gasset AR, Dohlman CH: The tensile strength of corneal wounds. Arch Ophthalmol 79:595-602, 1968. 1. Dhanda
Ophthalmol
![[Importance of the viability of the endothelium of corneal grafts].](/assets/img/hold.png)
