| Objective:To summarize preoperative evaluation and outcome of' corneal transplantation for limbal dermoids.Methods:85 eyes of 85 patients with limbal dermoids who underwent corneal transplantation from July 2004 to September 2014 at Shandong Eye Hospital were analyzed retrospectively.Eighty-two eyes were treated with tumor excision combined with partial lamellar sclerokeratoplasty,and the other three eyes were treated with penetrating keratoplasty.All patients diagnosed with limbal dermoids were further divided into two groups according to the designed group categories.Patients with dermoids characterized by no neovascularization surrounding the dermoids in the corneal stroma were classified as unneovascularization group,while those patients with dermoids characterized by neovascularization surrounding the dermoids in the corneal stroma were classified as neovascularization group.Unneovascularization group included 64 patients(64 eyes),and neovascularization group included 21 patients(21 eyes).Surgical methods:The operation was performed on infants and children under general anesthesia,and on adults under local anesthesia.First,the external rectus muscle was pulled with sutures,and the conjunctiva was cut open around the lesion to fully expose to the lesion.The size of the trephine was chosen according to the tumor size.Generally,the diameter of the trephine was 0.25 mm larger than the excised dermoid bed.The cutting depth was 1/4?1/3 corneoscleral thickness until the recipient bed was clear.Most donor eyes were preserved in low-temperature glycerin from an eye bank,and only a few from DX solution.The lamellar corneoscleral button(2/3 from the cornea,1/3 from the sclera)was 0.25 mm larger than the excised dermoid bed.The donor button was laid over the area of the cornea from where the dermoid was excised,and the corneal edge was sutured with 8-16 interrupted 10-0 nylon(Japan MANI).The conjunctiva was anchored to the limbus with 10-0 nylon.All surgeries were performed by one surgeon.Postoperative chemotherapy:All the patients received general corticosteroids and antibiotics after surgern.Tobramycin and dexamethasone eye ointment and recombinant bovine basic fibroblast growth factor gel were applied in order to promote restoration of the corneal graft epithelium.When the corneal graft epithelium was restored.0.02%fluorometholone eye drops four times everyday,pranoprofen eye drops four times everyday,cyclosporine eye drops two times everyday were applied to the patients The mean intraocular pressure was measured regularly.The size and location of the tumor.the associated ocular and systemic anomalies,the depth of the corneal penetration of tumor tissues,the preoperative and postoperative Best-corrected Visual Acuity(BCVA).graft survival and cosmetic outcomes.the prognosis of graft and host using the Anterior Segment Optical Coherence Tomography(AS-OCT)and surgical complications were recorded respectively.Visual acuity was tested using the Snellen chart and was converted into a logarithm of the minimum angle of resolution score for analysis.Sixteen patients(16 eyes)were not cooperative enough to perform visual acuity testing using the Snellen chart because of their younger age.The opacity of the graft was graded clinically on a scale of 0 to 4+(0=completely clear;1+?minimal haze seen with difficulty under direct illumination;2+=mild haze seen easily;3+=moderately dense opacity partially obscuring the iris details;4+=dense opacity completely obscuring all details of the intraocular structure).Statistical analysis was performed using the method of t-tests with SPSS 17.0 statistical software(SPSS Inc.,Chicago,IL,USA).When a P-value was less than 0.05,it was considered significant.Results:The average age at surgery was 5.3y(range,3mo to 36y).and there were 49 men and 36 women.The operations were performed in 41 right eyes and 44 left eyes,respectively.The mean follow-up time was 17.95mo(range,1 mo to 6y).Four patients were diagnosed with recurrent limbal dermoids.The limbal dermoids in 1 patient was recurrent following four years after excision and lamellar keratoplasty.and in 3 patients it was recurrent following simple excision.The mean size of dermoids was 6.1±1.6 mm;37 eyes were present with hair at the surface of the dermoids and other 48 eyes were absent with hair at the surface of the dermoids.62 dermoids were located inferotemporal quadrant of the eye and 23 dermoids were located other quadrant of the eye.Amplyopia was present in 29 eyes of patients and 8 eyes of patients had lipodermoids.Eighteen patients suffered from Goldenhar's syndrome with an accessory ear.In the unneovascularization group,sixty-four eyes were treated with tumor excision combined with partial lamellar sclerokeratoplasty and six eyes were performed with lipodermoids excision.In the neovascularization group,eigthteen eyes were treated with tumor excision combined with partial lamellar sclerokeratoplasty and two eyes were performed with lipodermoids excision;the other three eyes were treated with penetrating keratoplasty due to the dermoids involvement with whole cornea.We found that of the patients treated with surgery.75%of those in unneovascularization group had the involvement of the corneal deep stroma down to Descemet's membrane without involving it.and 25%of those had the involvement of the corneal superficial stroma;but in neovascularization group.3 patients(14.3%)had the involvement of the corneal deep stroma down to Descemet's membrane without involving it,15 patients(71.4%)had Descemet's membrane involvement and 3 patients(14.3%)had whole corneal involvement.There were significant difference between corneal involvement of the two groups(P<0.05).Preoperative BCVA ranged from counting fingers(CF)to 20/20.Postoperatively one year.81.1%(56/69)had a BCVA of 20/800 or better.In 43.4%(30/69)of patients,the BCVA was 20/40 or better and for 14.4%(10/69)of them it was 20/25 or better.In unneovascularization group,the preoperative BCVA was 20/200?20/20(0.41±0.32 logMAR)and the postoperative BCVA was 20/400?20/20(0.31±0.22 logMAR)postoperatively one year.The postoperative BCVA improved in 32 of 50 eyes(64%),remained unchanged in 8 eyes(16%),and decreased in 10 eyes(20%).In neovascularization group,the preoperative BCVA was 20/2000?20/20(0.75±0.4 logMAR)and the postoperative was 20/400?20/20(0.66±0.43 logMAR)postoperatively one year.The postoperative BCVA improved in 12 of 19 eyes(63.2%),remained unchanged in 4 eyes(21.1%),and decreased in 3 eyes(15.8%).There were no significant difference between the post-surgical BCVA of the two groups(t=1.584.P>0.05).84 patients markedly improved their cosmeic appearance,except one patient due to interface neovascularization and opacity.The grafts of 70.5%patients were present as 1+ opacity.21.1%as 2+ opacity,8.2%as 3+ opacity and none as 4+ opacity.In unneovascularization group,50 eyes were present as 1+ opacity,12 eyes as 2+ opacity.2 eyes as 3+ opacity and none as 4+ opacity.In neovascularization group.10 eyes were present as 1 + opacity.6 eyes as 2+ opacity,5 eyes as 3+ opacity and none as 4+ opacity.Using the Anterior Segment Optical Coherence Tomography(AS-OCT)the graft and host had good interface prognosis after operation.Graft rejection occurred in 3 patients with penetrating keratoplasty,but improved well under anti-rejection medications.No recurrence was noted after surgery.Microperforation was present in 1 patient and repaired during the operation.After surgery.prolonged reepithelialization occurred in 4 eyes,steroid glaucoma was seen in 2 eyes,interface neovascularization was present in 1 eye,and interface hemorrhage occurred in 1 eye.Conclusion:Tumor excision combined with partial lamellar sclerokeratoplasty is an effective and efficient approach to treat limbal dermoids.The majority of patients markedly improved their cosmetic appearance after surgery.The dermoids with neovascularization surrounding them in the corneal stroma invaded deeper tissues in the cornea than those with no neovascularization surrounding them in the corneal stroma.For performers with limited surgical experience,it is beneficial to develop an operation plan and conduct a preoperative evaluation to avoid surgical complications when excising tumors and lamellar cornea during the corneal transplantation operation. |
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