Clinical Observation Of High-risk Keratoplasty

Severe infection,chemical or thermal burns and other causes canmake widely putrescence ,perforation or corneal staphyloma.At thepresent time,high risk keratoplasty is still an important and effectiveway to save serious pathological changes of eye ball.Keratoplasty isalso an important way to take off blind.High risk keratoplasty ismainly include aspects as follows:(1)Vascularization (2)Severeinfection or perforation (3)Large graft size (>8.5mm) (4)Eccentricgraft (5)Bilateral graft (6)Previous graft (7)Yong recipient age (8)Previous glaucoma or aphakia(9)Multiple surgical procedures .Manipulationsduring perioperative period are important for the high risk patients toreduce graft rejection rate and to elevate survival rate.71 eyes of 63cases with high risk keratoplasty between 2000.1 and 2005.12 wereselected to observe the effective ways to reduce immunologic rejection rateand other complications.Result:1.For 52 of the 71 eyes (73.2%),thevision acurity was increased.50 transplants of the 71 eyes(70.4%)were transparent. 2. Immunologic rejection rate in different high riskpatients as follows: Severe infection or perforation (75%),)Multiplesurgical procedures(68.4%), Previous graft (66.7%), Vascularization(60.7%),Large graft size (56.8%), aphakia(53.3%), Previous glaucoma(42.1%),Bilateral graf (37.5%), Children keratoplasty(30.8%), Eccentricgraft(20%). 3.The other main complications :28 eyes(39.4%) hadvascularization,18 eyes (25.4%)had secondary glaucoma. 4. Theimmunologic rejection rate increased with the more united operationand more high risk factors.For high risk patients,we should pay moreattention to the manipulations during perioperative period asfollows:1.Manipulations during preoperative period :(1) Adopt thepart and the whole body consociation to use medicine according todifferent infection. Broad spectrum antifungal agents, especially thepolyene and triazole, is preoperative drug to fungal cornea ulcer.(2)Severe chemical or thermal burns : The patients of eyelids defection ,entropion and ectropion should take blepharoplasty. If lack of corneamaterial can adopt tarsorrhaphy, reconstruction of Tenon capsule oramniotic membrane grafting .Other processings: ① One who has dryeye syndrom, should adopt the artificial tears liquid or body serumafter the reconstruction of ocular surface.At the same time, adopttemporarily lacrimal punctum embolism.② Anti-infection cure.③Application of glucocorticoid:2 weeks after burn we should take theright amount of glucocorticoid, 3 weeks should reduce or stop using it.④Applying collagenase inhibitor or antioxidant inhibit degradationof collagen. ⑤ epidermis growth factor(EGF) etc. promote the repairof ocular surface.2. Manipulations during operation: (1) aphakia: Thediameter of corneal graft should larger than corneal bed with0.25-0.5mm.(2)For preoperative high IOP cases, we should adoptassociate-operation during penetrating keratoplasty. The effect iscertain with accomplishing the operation by one time, which canreduce the glaucoma occurrence by maximum degree and avoid thegraft opacity.(3) Avoiding take off crystalline lens as far aspossible.(4)Vascularization:Making use of Halon reasonablely. (5)choice of donator:for the case of bilateral graft, chooses the samedonator as far as possible. Adopt LKP for the case of the serious burnby fresh material. For the case of perforation which can not wait untilfresh cornea ,we can adopt the layer cornea material of the glycerinconservancy.3. Manipulations during postoperative period: Themedicine of the earlier period after operation.(1)Applyingglucocorticoid and CsA reasonablely.(2)Processings of complications :Although graft rejection can lead to graft failure, most rejections canbe readily controlled if appropriate management is commenced at theproper time. In the high-risk situations however, systemic steroids,and other immunosuppressive drugs such as cyclosporin andtacrolimus (FK506) are of proven benefit, both for treatment andprevention of rejection. For cornea new vessel, the glucocorticoid andCsA are mainly medicine.We should dismantle the loose suture intime.According to the degree of IOP we should adopt differentoperative or pharmacal way.