A CASE OF REJECTION IN A PATIENT WITH TURNER'S SYNDROME AND SUBMITTED TO DEEP LAMELLAR KERATOPLASTY (DLK).
Luigi Mele MD, Marco Giovanni Iorio MD, Sandro Sbordone MD, Mario Bifani MD. Department of Ophthalmology. Second Univeristy of Naples
Luigi Mele MD.
Sandro Sbordone MD.
Oculista
Oculista
Dipartimento multidisciplinare di Specialità Medico Chirurgiche ed Odontoiatriche
Dipartimento multidisciplinare di Specialità Medico Chirurgiche ed Odontoiatriche
Seconda Università degli Studi di Napoli
Seconda Università degli Studi di Napoli
Mario Bifani MD.
Marco Giovanni Iorio MD.
Oculista
Dipartimento multidisciplinare di Specialità Medico Chirurgiche ed Odontoiatriche
Dipartimento multidisciplinare di Specialità Medico Chirurgiche ed Odontoiatriche
Seconda Università degli Studi di Napoli
Seconda Università degli Studi di Napoli
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ABSTRAC Introduction Deep lamellar keratoplasty (DLK) is a surgical technique that consists in removal of corneal epithelium and stroma up to Descemet's membrane with subsequent affixing of a corneal flap which have been previously removed both endothelium and Descemet's membrane.
Tetrahydrozoline coll x 3 was practiced. In the seventh day novasi were completely regressed stopping at the flap receiver ring junction. Conclusions Despite the presence of a virtual space between transplanted stroma and receiver provide a neovessels preferential progression way; rejection has brilliantly solved in short time thanks to the presence of the receiver endothelium who played a major role in the inflammatory response.
Essential prerogative is the integrity of corneal endothelium which is previously evaluated by careful biomicroscopic examination and primarily by endothelial microscopy. Indications are constituted by all those diseases where the corneal endothelium is intact. Advantages are the best mechanical stability of the flap and the best control of astigmatism. disadvantage is the difficulty of the technique. The most relevant intraoperative complication consist in drilling, while the post-operative is the rejection without endothelium involvement. We present a case of rejection at the stromaendothelium interface.
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Subjects and metods Introduction
Patient was affected by Turner syndrome with keratoconus in stage III of Amsler classification, no other general and ocular disorders. BCVA resulted 2/10 with irregular astigmatism. Patient could not tolerate L.A.C. For these reasons, she was subjected to surgery DLK.
Deep lamellar keratoplasty is an alternative surgical technique to penetrating keratoplasty for the treatment of many different diseases characterized by the involvement of the epithelium and the corneal stroma. It’s a fairly complex method which provides an initial semi drilling patient’s corneal trepanation, followed by careful manual removal of the stroma, up to the Descemet membrane. Stromal delamination can be carried out in dry, following the classical technique starting from the line of trepanation to the center, or following the four quadrants technique. The latter provides the incision of the cornea in order to draw four quadrants that
Results After ten months, during which the postoperative course was normal, was appeared painful, flap edema with large neovascularization from flap reciver ring junction to endothelial stromal interface, with no signs of uveitis. Therapy with betamethasone cp. 1 mg x 1, dexamethasone coll. x 6, Atropine coll. 1% x 2, 2
The most frequent intraoperative complications are represented by the Descemet's membrane micro and macroperforations, which make urgent conversion to penetrating keratoplasty, and possible and inevitable presence of intrastromal residues in the interface that may invalidate the visual result.
can be so attacked individually and in succession, by removing the stroma in centrifugal or centripetal direction. To dry delamination contrast some techniques that include the use of intrastromal injections of air, BSS, trypan blue or viscoelastic substances, which would reduce the adhesion between stromal lamellae, thus allowing the removal, and improve visualization of the Descemet membrane, facilitating the retrieval of the correct cleavage plane. Finally, a further variant provides for the injection of air into the anterior chamber in order to obtain a better stereoscopy, therefore favoring the delamination.
The main postoperative complications are represented by the possibility of a double anterior chamber formation and epithelial or stromal rejection episodes. In this study we present a case of stromal rejection in one eye DLK treated at corneal transplants Center of Second University of Naples directed by Prof Mario Bifani.
Subsequently a lenticulo is prepared to be implanted that is subjected to manual removal of the corneal epithelial layer with Descemet's membrane and then it’s juxtaposed to the recipient Descemet's membrane. At this point, a separate stitches or continuous single or double antitorque suture is performed.
Patients and metods The patient was 24 years old at time of surgery.
The advantages of this surgical procedure are multiple, in fact, the entire surgery is performed on closed bulb, with a considerable reduction of the infectious risks associated to the bulb opening, so the significant reduction of post-operative complications. Higher than the penetrating keratoplasty, a greater mechanical stability of the flap is present and consequently a better margin confrontation between lenticulo and recipient tissue, reducing post-operative astigmatism. Lamellar keratoplasty allows to obtain a more rapid visual recovery compared to penetrating keratoplasty, howeverensuring, in case of severe intra-operative complications, the exchange of the intervention. Failure to remove the epithelium, in this type of technique allows to exclude any endothelial discards, also use corneas with a small endothelial population, which could not be implanted in the course of full-thickness keratoplasty.
From clinical point of view she appeared affected by Turner syndrome and hypothyroidism. Objectively, she had a bilateral keratoconus stage III according to Amsler staging, characterized by a topographically and opthalmologically measured astigmatism, highly irregular and undeterminable with a corneal curvature greater than 48D. Patient had 2/10 BCVA, while the ophthalmometric examination proved not determinable in relation to the high astigmatism degree detected (> 60D) and high mires irregularity. Surgical technique involved the use of general anesthesia followed by a corneal trephination 8 mm diameter and a 2/3 depth of the minimum peripheral pachimetric thickness. The delamination was carried out by dry technique, while the cornea implanting was created 8.25 mm in diameter. The lenticulo was sutured with the use of a double torsion suture. Patient was then subjected to a
The main disadvantages are the intervention length and difficulty determining a long surgical learning curve. 3
presence of a virtual space between Descemet's receiver and the corneal stroma of the donor provides a way to neovascularization of preferential progression, through which the immune system of the patient subjected to DLK is activated.
subconjunctival injection of methylprednisolone and gentamicin and medicated with intramuscular Cefazoline 1 mg x 2, betamethasone 1 x 4 mg, betamethasone and chloramphenicol eye drops x 5. Results Three months after surgery, patient had a perfectly transparent flap with tight in situ suture and interface between Descemet's membrane of the recipient and the implanted lens stroma clean. The ophthalmometric examination noted a regular astigmatism of about 7 D; l 'AVCA was 1/10 while the BCVA was 8/10 with sf. + 1 and cyl. + 4 (90 °).
Bibliography 1. Sögütlü Sari E, Kubaloglu A, Unal M, Piñero Llorens D, Koytak A, Ofluoglu AN, Ozertürk Y. Penetrating keratoplasty versus deep anterior lamellar keratoplasty: comparison of optical and visual quality outcomes. Br J Ophthalmol. 2012 Jun 20 2. Olson EA, Tu EY, Basti S. Stromal Rejection Following Deep Anterior Lamellar Keratoplasty: Implications for Postoperative Care. Cornea. 2012 Jun 6 3. Huang T, Zhang X, Wang Y, Zhang H, Huand A, Gao N. Outcomes of Deep Anterior Lamellar Keratoplasty Using the Big-Bubble Technique in Various Corneal Diseases. Am J Ophthalmol. 2012 May 23 4. Tan DT, Dart JK, Holland EJ, Kinoshita S. Corneal transplantation. Lancet. 2012 May 5;379(9827):174961. 5. Lyall DA, Srinivasan S, Roberts F. A Case of Interface Keratitis Following Anterior Lamellar Keratoplasty. Surv Ophthalmol. 2012 Apr 28 6. Rama P, Knutsson KA, Razzoli G, Matuska S, Viganò M, Paganoni G. Deep anterior lamellar keratoplasty using an original manual technique. Br J Ophthalmol. 2012 Mar 18. 7. Tzelikis PF, dos Santos JD, Garcez RC, Akaishi L. Deep anterior lamellar keratoplasty by big-bubble technique. Arq Bras Oftalmol. 2011 NovDec;74(6):435-40.
After about 10 months patient returns to our attention as referred pain symptoms and decrease in visual acuity. Biomicroscopic slitlamp examination indicated a significant edema of the flap with the presence of large new vessels ranging from junction between the implanted lenticulo tissue and recipient endothelium-stromal interface. Also dotted stromal opacity and deposits were present in the interface. Patient was subjected to an intense therapy with betamethasone Retard cps x 1, dexamethasone coll. X 6, Atropine coll. x 2 and tetryzoline hydrochloride coll. x 3. After 7 days of treatment the pain symptoms had decreased and the clinical markedly improved. Were still only the interface neovascularization and stromal opacity soft uninteresting the optical zone, which allowed the patient an BCVA of 6/10. Conclusions Although the manual deep lamellar keratoplasty represents a more convenient surgical technique than the penetrating keratoplasty because it allows to cancel entirely the risk of endothelial episodes of rejection, since the corneal endothelium of the patient treated is not replaced, the possibility of a rejection stromal not exclude that, although rare, can still occur since the 4
8. Bhatt UK, Fares U, Rahman I, Said DG, Maharajan SV, Dua HS. Outcomes of deep anterior lamellar keratoplasty following successful and failed 'big bubble'. Br J Ophthalmol. 2012 Apr;96(4):564-9. Epub 2011 Dec 1. 9. Ang M, Mehta JS. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty. Ophthalmology. 2011 Nov;118(11):2306-7. 10. Deep anterior lamellar keratoplasty van den Biggelaar FJ, Cheng YY, Nuijts RM. Ophthalmology. 2011 Nov;118(11):2305-6
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