**8.1.7 Recurrence**

26 Keratoplasties – Surgical Techniques and Complications

Controlled using cautery, compression with viscoelastic, or tamponade with sponges soaked with epinephrine 1:1000. If hyphema is persistent and provokes a rise in intraocular

Infectious keratitis itself explains the great inflammation that is seen after PK in these patients. The risk of severe postoperative inflammation can be diminished by gentle manipulation during surgery and the meticulous removal of all inflammatory material of the anterior chamber. The aggressive control of postoperative inflammation is also essential for the prevention of synechiae formation. Usually the uveitis is solved with the aid of cicloplegic and corticosteroid drugs, but the latter should be used with caution in fungal and

Fig. 16. Corneal ulcer by *Aspergillus flavus ,*three days Post- keratoplasty

Severe inflammation causes trabeculitis and this causes elevation of the intraocular pressure. Besides peripheral anterior synechiae if present and not broken during surgery can impeed aqueous outflow and cause secondary glaucoma. Usually elevation of intraocular pressure can be controlled with beta blockers and systemic acetazolamide while the inflammation

Careful handling of the donor cornea intraoperatively is imperative to avoid damaging the epithelium. Good wound apposition and prevention of an overriding edge leads to better tear-film distribution and a reduced incidence of epithelial defects. A persistent epithelial defect has the potential to secondary infection thus reepithelialization and the maintenance of an intact epithelium is critical for postoperative wound healing, graft survival, and protection against infection and melting. Initial treatment requires application of topical lubricants and if it persists a permanent or temporary tarsorrhaphy early in the

pressure, it should be immediately evacuated. Fig. 15

**8.1.4 Anterior uveitis** 

*Acanthamoeba* keratitis.

**8.1.5 Ocular hypertension** 

**8.1.6 Persistent epithelial defect** 

diminishes.

The indiscriminate use of corticosteroids postoperatively can cause recurrence of the infection, especially in micotic keratitis. In our experience we report recurrence in 31, 4%, being the most frequent cause fungal keratitis, as Rao et al 1999 reported. 50% of these recurrences needed a new PK to be free of infection. Time of recurrence varied between 1-42 days.

Fig. 17. Therapeutic keratoplasty, *Mycobacterium chelonae* corneal ulceration 30 Days post LASIK

Fig. 18. Same eye showing recurrence of infection (*Mycobacterium chelonae)* Involving the entire graft

Therapeutic Keratoplasty for Microbial Keratitis 29

Fig. 20. Post Therapeutic keratoplasty in Candida keratitis, with clear button and cataract.

Severe inflammation causes if left untreated, can cause great alteration and disorganization of intraocular structures and atrophia. Despite all efforts to maintain globe integrity we still

Therapeutic keratoplasty is generally an emergency, high-risk procedure that challenges the surgical and medical skills of the corneal surgeon. It requires meticulous attention to detail and careful postoperative monitoring. Therapeutic keratoplasty play a definitive role in the treatment of microbial keratitis refractory to medical therapy. Advances in microsurgical technique, antimicrobial therapy new and more powerful antibiotics (fourth generation quinolones), and control of inflammation have resulted in an improved prognosis for

Alizadeh H, Niderkorn Y, & McCulley J. 1998. Acanthamoebic keratitis In: *Ocular infections* 

Blackman HJ, Rao NA, Lemp MA, & Visvesvara GS. 1984 Acanthamoeba keratitis successfully treated with penetrating keratoplasty. *Cornea,* 3:125-130. ISSN 0277-3740 Donnenfeld ED, & Solomon R. 2005 Chapter 139 Therapeutic keratoplasty, In Cornea,

Ficker LA, Kirkness C, &Wright P. 1993. Prognosis for keratoplasty in Acanthamoeba

outcome of bacterial keratitis at King Khaled Eye Specialist Hospital. *Int* 

Krachmer, Mannis, & Holland 1695-1704. Elsevier Mosby ISBN 0323032150

Holland GN, Wilhelmus KR. 1062-1071. Mosby Co. 0-8016-6757-7 St Louis Missouri USA. Al-Shehri A, Jastaneiah S, &Wagoner MD. 2009. Changing trends in the clinical course and

can find phthisis in 2, 98% of the therapeutic keratoplasties.

therapeutic keratoplasty in cure and improved visual outcomes.

*Ophthalmol*. 29; 143-152. ISSN 0165-5701

keratis. *Ophthalmology*; 100:105- 10. ISSN0161-6420

**8.2.4 Phthisis bulbi** 

**9. Conclusion** 

**10. References** 

*and Immunity*. Pepose JS,

Philadelphia.

Recurrences can be avoided by performing a careful excision of the recipient cornea including all the infected material and with as adequate postoperative antibiotic and corticosteroid management. In our experience in fungal keratitis an Non tuberculous *Mycobacterium* we observed 31.34% recurrences. Fig. 17,18.

#### **8.2 Late-onset complications 8.2.1 Secondary glaucoma**

Adequate control of postoperative inflammation and careful liberation of synechiae during surgery lowers the incidence of secondary glaucoma which can endangers keratoplasty success. We found a incidence of secondary glaucoma of 22,4%. Only 4, 47% patients needed a filtering surgery to control intraocular pressure. Fig. 19.

Fig. 19. Some patient needed Ahmed valvule for hypertension control
