Thomas John, MD

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Confocal Microscopy of Graft Rejection in
Descemetorhexis with Endokeratoplasty
Thomas John, MD Clinical Associate
Professor Loyola University at Chicago Maywood,
Illinois Ritika Patel Chicago Medical School
ASCRS MEETING 2008 CHICAGO, IL
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John T, Patel R Confocal Microscopy of Graft
Rejection in Descemetorhexis with Endokeratoplasty

• PURPOSE To report the confocal microscopic
  findings in real time within the human cornea
  during graft rejection following DXEK surgery.
• SETTING/VENUE This study was performed in the
  office setting in Tinley Park, Illinois.
• METHODS Four eyes of 4 patients with active
  corneal endothelial graft rejection after DXEK
  were clinically evaluated, and serial images
  using ConfoScan 3 confocal microscope (Nidek
  Inc., Freemont, CA) from 3 of these patients were
  examined to evaluate the cornea from the
  endothelium to the epithelial surface and look
  for keratic precipitates (KPs), active
  keratocytes, macrotracks (indicative of corneal
  edema) and changes in the morphology of
  endothelial cells in the grafted donor corneal
  disc. Data regarding number, morphology, and
  distribution of the KPs were recorded from 10
  different fields. The numbers and morphology of
  active keratocytes versus inactive keratocytes in
  the stroma were recorded in 50 fields. The
  characteristics of macrotracks were also recorded
  from 50 fields. Automated morphometric analysis
  was done for cell density, pleiomorphism, and
  polymegathism of endothelial cells, and this was
  compared top that of normal endothelium.
• RESULTS The average age of patients in this
  study was 75.5 years (range 72-84 years). All
  patients were caucasian females. In 2 of the 4
  patients the right eye was involved in the graft
  rejection. On confocal microscopy (CM), KPs were
  seen as highly reflective, dense, spherical or
  ovoid bodies that were adherent to the corneal
  endothelium. These KPs can be widely distributed
  or grouped together. The active keratocytes
  appear as large, hperfluorescent, fusiform or
  spindle shaped bodies with cytoplasmic processes
  extending within the stroma. These are much
  larger compared to the inactive keratocytes that
  appear dull and smaller. In addition, numerous
  macrotracks appear as curvilinear tracks that may
  be vertical, horizontal, or oblique within the
  field. The automated statistical analysis of the
  endothelial cells showed that although the total
  numbers of endothelial cells were within the
  normal limit, there was a difference in the mean
  cell size and shape of endothelial cells in those
  with corneal endothelial graft rejection as
  compared to normal endothelium without graft
  rejection.
• CONCLUSIONS To our knowledge, this is the first
  study that shows the use of CM to evaluate in
  real time the changes in the corneal
  endothelium, stroma, and epithelium that occur as
  a result of corneal endothelial graft rejection
  after DXEK surgery. Distinct morphological
  features and distribution of KPs on the corneal
  endothelium were noted. The presence of active
  keratocytes and corneal edema was also noted
  which may contribute to visual loss during
  corneal graft rejection.
• FINANCIAL DISCLOSURE John, T None

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John, T
S/P DXEK, Graft Rejection
Case 1
ASCRS 2008, Chicago, IL

Case 3
Case 2
Case 4
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Confocal Microscopy of Graft Rejection following
DXEK

Confocal microscopy of keratic precipitates.
These appear as cells that are highly reflective,
spherical (yellow box-arrow) or ovoid bodies (red
box-arrow), that are adherent to the donor
corneal endothelium. They can be scattered or
can appear in clumps (blue curved-arrow).
Anterior chamber is seen to the right (blue star).

Confocal microscopy of keratocytes in acute
DXEK-graft-rejection The active keratocytes
appear as hyperfluorescent, fusiform shaped
bodies (yellow arrows) compared to the inactive
keratocytes (red star) that appear as dull,
fusiform bodies.

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Confocal Microscopy of Graft Rejection following
DXEK
Confocal microscopy of macrotracks (arrows)
within the stroma following DXEK-graft-rejection.
These appear as dark, curvilinear tracks within
the stroma that can be horizontal, vertical or
oblique.

Confocal microscopy of DXEK, donor-recipient
interface (curved arrow). Increased reflectivity
is seen at the interface.
John, T
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Figure 12 Results of confocal microscopy of
corneal graft rejection as detected months after
DXEK surgery. (cpf cells per field)
Cell sides analysis (pleomorphism). Normal cell
pleiomorphism is gt59.6, therefore results show
that there is less variation in cell shapes after
graft rejection.
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Confocal Microscopy of Graft Rejection in
Descemetorhexis with Endokeratoplasty
Thomas John, MD Clinical Associate
Professor Loyola University at Chicago Maywood,
Illinois Ritika Patel Chicago Medical School
ASCRS MEETING 2008 CHICAGO, IL