Pediatric Keratoplasty

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Pediatric Keratoplasty

• Presented by
• Dr. Mohammad Abdullah Bawtag
• VitreoRetinal Consultant

Sanaa University 2022
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History of Pediatric Keratoplasty
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• 1824 Reisinger First animal graft and coined
  the term keratoplasty
• 1831 Dieffenbach proposes partial-thickness
  keratoplasty (LKP, extraocular procedure)
• 1846 First use of general anesthesia ether, at
  the Massachusetts General Hospital, Boston, MA
• 1878 Arthur von Hippel, invented circular cutting
  trephine, blades of different diameters, a key
  for winding up the watch mechanism
• 1888 Arthur von Hippel, first successful LKP in
  man
• 1908 Plange First human lamellar autograft
  (clear cornea from blind eye to opposite, scarred
  eye of the same patient). Graft remained clear
  for 5 years.
• 1912 Magitot Use of human cornea previously
  preserved in an antiseptic fluid for corneal
  transplantation.

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• In 1905 The first cornea transplant was performed
  by Eduard Zirm .

• in 1955 Tudor Thomas ,conceived the idea of a
  donor system for corneal grafts and an eye bank
  was established in East Grinstead .

• Real progress in past 40 years- KPro design,
  material, prevention and management of
  complications

• Widespread use limited by early and late
  complications

• The Dohlman or Boston Keratoprosthesis is the
  most popular now

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Terminologies of Pediatric keratoplasty
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keratoplasty
Corneal Transplantation
Corneal Grafting
Keratoprosthesis
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Definitions of Pediatric keratoplasty
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The cornea is the transparent front part of
the eye that covers the iris, pupil and anterior
chamber.
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Keratoplasty simply means surgery to the cornea.
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• Keratoplasty is a surgical procedure where a
  damaged or diseased cornea is replaced by donated
  corneal tissue (the graft).
• When the entire cornea is replaced it is known as
  Penetrating Keratoplasty and when only part of
  the cornea is replaced it is known as lamellar
  keratoplasty.

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Keratoprosthesis is a surgical procedure where
a severely damaged or diseased cornea is replaced
with an artificial cornea to restore useful
vision or to make the eye comfortable in painful
keratopathy
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• The graft is taken from a recently deceased
  individual with no known diseases or other
  factors that may affect the chance of survival of
  the donated tissue or the health of the
  recipient.
• Donors can be of any age, as is shown in the case
  of Janis Babson, who donated her eyes after dying
  at the age of 10.
• Corneal transplantation is performed when
  medicines, keratoconus conservative surgery and
  cross-linking can no longer heal the cornea.
• This surgical procedure usually treats corneal
  blindness,with success rates of at least 41 as
  of 2021.

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Indications of Pediatric keratoplasty
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• 1- With Associated Glaucoma
• Congenital glaucoma
• Peterss anomaly
• Other anterior segment dysgenesis
• 2. Without glaucoma
• Sclerocornea
• Dermoid
• Birth trauma
• Metabolic disease
• Keloid
• Aniridia

• Acquired non-Traumatic
• Keratoconus
• Infective keratitis with or without perforation
• Post infective corneal/ Corneo-iridic Scars
• Keratomalacia

Anterior segment photographs of eyes where
congenital corneal opacity spontaneously
regressed. a, b The right eye of a female patient
with Peters anomaly at 25 days (a) and 15 months
of age (b). c, d The left eye of a male patient
with Peters anomaly at 22 days (c) and 6 months
of age (d). e, f The left eye of a male patient
with Peters anomaly
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Types of Pediatric keratoplasty
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• Types
• Based on Location
• Central
• PeripheralCircular, oval, crescentic, annular,
  semilunar, rectangular or strip graft
• Totalcentral and peripheral
• Corneoscleral
• Based on Stem-cell Transplantation
• Non-stem cell KP
• KP with stem cell transplantation (SCT)

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• Types of keratoplasty
• Based on the thickness of the cornea
  transplanted, keratoplasty can be divided as
• Penetrating keratoplasty- involved full thickness
  of the cornea.
• Lamellar keratoplasty- involves a transplantation
  of a part.
• Anterior lamellar SALK, MALK, DALK, TALK
• Posterior lamellar DLEK, DMEK, DSAEK

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Contraindications of Pediatric keratoplasty
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• Dry Eye
• Blepharitis
• Ectropion
• Entropion
• Recurrent ocular infection
• Melting cornea
• Herpetic infection
• Uveitis
• Uncontrolled Glaucoma

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Challenges of Pediatric keratoplasty
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• Sever Ocular pathology
• Technically difficult
• Smaller eye
• Elastic sclera
• Shallow AC
• Anterior displacement iris/ Lens
• Young age
• Poor cooperation
• Hard to examine
• Sudden rapid rejection

The patients are different The Eyes are
different The disease are different The surgery
and anesthesia are different
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Complications of Pediatric Penetrating
keratoplasty
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• Allograft rejection
• Corneal scarring and neovascularization
• Iridocorneal adhesions
• Glaucoma
• Cataract
• Wound dehiscence
• Amblyopia
• Corneal steepening and high astigmatism
• Graft infection and ulcer
• Endophthalmitis
• Persistent epithelial defect
• RD
• Phthisis

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Alternatives to Pediatric keratoplasty
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• Contact lenses
• Phototherapeutic keratectomy
• Intrastromal corneal ring segments
• Corneal collagen cross-linking

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Pre operative Evaluation

• ? Electroretinography (ERG) and Visually Evoked
  Response (VER) helpful in predicting the visual
  potential.
• ? Pre operative Ultrasound examination to rule
  out presence of Retinal Detachment and other
  posterior segment abnormalities.
• ? IOP should be maximally controlled before
  surgery

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Surgical Procedure Keratoplasty
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Animations Videos for Keratoplasty
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Postoperative Care of Pediatric keratoplasty
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• First 2 months
• 2-3x / week
• Frequent Postopretive EUAs
• Early suture removal
• Long term slow taper of topical steroid over
  one year
• Sedation p.r.n
• No vaccination for one year
• Co-management with pediatric ophthalmologist
  necessary
• Optical correctio ASAP after suture removal

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Prognosis

• Best
• Multiple Graft failure in a relatively
  non-inflamed eye with intact tear and blink
  mechanisms (following dystrophies, infections,
  etc)
• Aniridia and other limbal stem cell failure
  cases Intermediate
• Chemical burns, HSV
• Worst
• Autoimmune diseases
• Mucous membrane pemphigoid
• Stevens-Johnson syndrome
• Chronic uveitis

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Thanks