**5. Conclusion**

Keratoplasty is one of the ocular surgeries that contribute with the reinsertion to job and daily activities and quality life of patients. For these reason, it is very important to study the complications and how to protect cornea before and after keratoplasty for visual health and integrity of the eye and to prevent it. There are new diagnostic techniques so useful worldwide (PCR, new chromogenic agar, immunological test, diagnostic test) to identify the microbes and to choice the good therapy. The reports of the type of microorganisms which cause the lesions are not the same in all countries: In Asia, mycotic infections are most frequent than in America, where bacterial reports of microbial infections are most frequent listed on literature.

Protocols to perform microbial sampling to identify not only bacteria, but also fungi, viruses and acanthamoeba and also immunological test should be a requirement for the protocol clinical management of infection after corneal transplantation, as well as the overall health status of the patient habits and systemic associations to prevent corneal damage. More and more cases appear around the world, by one or other reasons, and it is important to take care of the type of microorganism present, the therapeutic protocol: signs, culture and treatment. New therapeutic drugs must be studied, especially for fungus findings, like variconazole, and take special care for mix infections: bacteria-fungus for the differential diagnosis. Dry eye or not lubrication can contribute to microbial infections, because the tears are the immune protection for the cornea and the artificial tears help to remove toxins and mycotic spores. Some cases needs treatment immediately but the use or corticoids it is not recommended because it can decrease the immune response against the infection. There are no therapy against endotoxins that are responsible of the major damage of the stromal tissue, causing toxic anterior segment syndrome (TASS) and new techniques of therapy like the use of intracamerular antibiotics, and some recommendations like the use of non-ionized water or detergents during surgery must be evaluated to include in protocols. Another factor to have on mind to prevent infections after keratoplasty is the immunological associations with systemic diseases, and also the maintenance of the cleaning regimen for contact lenses. It is main important for next studies to evaluate if the previous permanent make up for esthetical reasons around the eye, perhaps it can interfere the microbial equilibrium of normal flora and let the opportunistic flora to colonize the eye and cause infections. Among some aftercare corneal transplant recommendations after this finding around the world it should look the next factors:


114 Keratoplasties – Surgical Techniques and Complications

them by antigen presenting cells. These T cells can lead to tissue damage of the graft by the direct elimination of graft cells (killer T cells) or the production of proinflammatory cytokines such as tumor necrosis factor, interleukin-1, and interferon. These cytokines are vasoactive and perpetuate the inflammatory cell recruitment and infiltration. As a result, graft inflammation progresses, leading to tissue distortion, vascular insufficiency, and cell

By the other hand, the chronic rejection occurs in 50% of transplant patients within 10 years after transplantation. This form of rejection is characterized by the development of occlusion of blood vessels luminal progressive thickening of the intima of medium and large artery walls. Chronic rejection is a pathological response of the tissue remodeling that takes place at a variable rate after graft endothelial cells are traumatized by mechanical damage, ischemia, and immune system during and after the transplant. Damaged vascular endothelial cells produce cytokines and tissue growth factors that initiate vascular repair, causing the underlying smooth muscle cells to begin proliferating. Large amounts of intimal matrix occur, leading to vascular wall thickening stop growing. Slowly progressive reduction in blood flow, results in regional tissue ischemia, cell death and tissue fibrosis.

Keratoplasty is one of the ocular surgeries that contribute with the reinsertion to job and daily activities and quality life of patients. For these reason, it is very important to study the complications and how to protect cornea before and after keratoplasty for visual health and integrity of the eye and to prevent it. There are new diagnostic techniques so useful worldwide (PCR, new chromogenic agar, immunological test, diagnostic test) to identify the microbes and to choice the good therapy. The reports of the type of microorganisms which cause the lesions are not the same in all countries: In Asia, mycotic infections are most frequent than in America, where bacterial reports of microbial infections are most frequent

Protocols to perform microbial sampling to identify not only bacteria, but also fungi, viruses and acanthamoeba and also immunological test should be a requirement for the protocol clinical management of infection after corneal transplantation, as well as the overall health status of the patient habits and systemic associations to prevent corneal damage. More and more cases appear around the world, by one or other reasons, and it is important to take care of the type of microorganism present, the therapeutic protocol: signs, culture and treatment. New therapeutic drugs must be studied, especially for fungus findings, like variconazole, and take special care for mix infections: bacteria-fungus for the differential diagnosis. Dry eye or not lubrication can contribute to microbial infections, because the tears are the immune protection for the cornea and the artificial tears help to remove toxins and mycotic spores. Some cases needs treatment immediately but the use or corticoids it is not recommended because it can decrease the immune response against the infection. There are no therapy against endotoxins that are responsible of the major damage of the stromal tissue, causing toxic anterior segment syndrome (TASS) and new techniques of therapy like the use of intracamerular antibiotics, and some recommendations like the use of non-ionized water or detergents during surgery must be evaluated to include in protocols. Another factor to have on mind to prevent infections after keratoplasty is the immunological associations with systemic diseases, and also the maintenance of the cleaning regimen for contact lenses. It is main important for next studies to evaluate if the previous permanent

destruction - all of which may eventually compromise graft function.

**5. Conclusion** 

listed on literature.


To prevent post surgical infections the disinfection protocols are the main factor to consider for minimize complications: before starting the surgical procedures, all of the recipient eyes (including eyelids and conjunctiva) can be rinsed with povidone iodine solution, 5%, that was allowed to act for 3 to 5 minutes. After drying the periocular surface, the operation field was covered with sterile drapes and PK can be performed as follows: rinsed with sterile solution (balanced salt solution, it is recommended to introduce acetylcholine chloride (like Miochol-E) into the anterior chamber. Prior to donor trephination and the graft's sutural fixation, the donor's endothelium was covered by sodium hyaluronate, 1% (Healon ophthalmic viscosurgical device). To fix the grafts, a double-running cross-stitch suture with 10-0. And the use of an antibiotic ointment administered at the end of surgery.

It is important also instruct patients avoid restrictions and talk about postsurgical care to prevent fails. Some of these are: To take de prescription of antibiotics and drugs, and the restriction recommended by American Ophthalmology Association:


Other important recommendations to verify are:

Recruitment of donor tissue : de donor must be removed within six hour after death, the viable storage period of the removed cornea-scleral button is two weeks, grafts donors < 12 months or > 70 years are preferably not to be used and for more security it is also important not use corneas from death of unknown causes, certain infectious diseases like Jacob-Creutzfeld, SSPE, progressive multifocal, leuko-encephalopathy (CNS), certain systemic infection (AIDS, septicemia, syphilis, viral hepatitis), leukemia and disseminated lymphoma, intrinsic eye diseases (tumors, active inflammations, previous intra-ocular surgery), with respect to the recipient cornea : absence of corneal sensations, stromal vascularization, corneal thinning at the expected recipient-donor margin, active inflammation) and also it is so important to verify the surgical procedure : decide about graft size, usually graft size is no bigger than 8,5 mm in diameter to avoid post-keratoplasty increase in intra-ocular pressure, anterior synechiae and

The Complications After Keratoplasty 117

Buehler P O, Schein O D, Stamler J F, Verdier D D, Katz J. (1992*).* The increased risk of ulcerative keratitis among disposable soft contact lens users. *Arch Ophthalmol*; 110: 1555-8. Butler KH, T. Dua, H. Edwards, R. James S. Lowe. (2001). In vitro model of crystalline

*Investigative Ophthalmology & visual science*.2001. vol. 42 no. 6 1243-1.246. Carringhton, LM, Albon J., Anderson I, Kamma C. Boulton M. (2006). Invest Ophthalmology

Chalupa E, Swarbrick H, Holden B, Sjöstrand J. (1987). Severe corneal infections associated

Confino J, Brown SI. (1985). Bacterial endophthalmitis associated with exposed monofilament sutures following corneal transplantation. Am J Ophthalmol 99:111—3. Cunnusamy, K. Chen PW, Niederkorn JY. (2010) Paradigm shifts in the role of CD+ T cells

Dana MR, Goren MB, Gomes JA, et al. (1995). Suture erosion after penetrating keratoplasty.

Delgado, E., Durán, P., Neira O. y Veloza, G. (2008). Queratitis por Pseudomonas aeruginosa

Fukuda, K., Yamada N., Fujitsu Y., Kumagai N. Nishida T.(2002). Inhibition of eatoxin

García Serrano, JL, Domínguez, Y, Serrano Laborda, D. (2004). Recurrencia de endoftalmitis

Gleich GJ, Adolphosn CR, Leiferman KM. The biology of the eosinophilic leukocite. Annu

Holden B A, Sweeney D F, Sankaridurg P R, Camt N, Edwards K, Stretton S, et al. (2003).

Kumagai N, Fukuda K, Nishida T. (2005). Enhancement of conjunctival inflammation by

Maier, P. MD; F. Birnbaum, MD; Böhringer, D. MD; Reinhard, MD. (2010). Toxic Anterior

Marquart M E, Caballero A R, Chomnawang M T, Brett A, Twining S S, O'Callaghan R J.

McCulley JP, Alizadeh H, Niederkorn JY. (2000). The diagnosis and management of

causes corneal erosions. *Invest Ophthalmol Vis Sci*; 46: 3761-8

Acanthamoeba keratitis. *CLAO J* ;26:47-51.

Annual meeting 77ª of ARVO in Fort Lauderdale, Florida, May 1 – 5. Kwong M, Evans D, Minjian N I, Cowell B, Fleiszig S. Human tear fluid protects against

Reporte de un caso. *Revista Chilena de Infectología*. 2008; 25 (4): 295-300. Driebe WT, Stern GA. (1983). Microbial keratitis following corneal transplantation. *Cornea* 2:41. Fong LP, Ormerod LD, Kenyon KR, et al.(1988). Microbial keratitis complicating penetrating

asociada al uso de lentes de contacto de hidrogel de silicona de última generación:

expression in human corneal fibroblasts by IFN-gamma. International archives of

bacteriana después de la queratoplastia penetrante. *Arch Soc Esp Oftalmol*., vol.79,

Microbial keratitis and vision loss with contact lenses. *Eye Contact Lens*; 29S: S131-4.

corneal epithelial ablation in experimental allergic conjunctivitis. Presented in the

Pseudomonas aeruginosa keratitis in a murine experimental model.(2007). *Infect* 

Segment Syndrome Following Penetrating Keratoplasty. *Archieves of ophthalmology*.

(2005). Identification of a novel secreted protease from *Pseudomonas aeruginosa* that

Vis. Sci. May :47 (5) :1886-94.

*Cornea* 14:243—8.

with contact lens wear. *Ophthalmology*; 94: 17-22.

keratoplasty. *Ophthalmology* 95:1269--75.

allergies and immunology.

Rev Med 44 :85 – 101, 1993.

discussion S143-4, S192-4.

*Immun* ; 75: 2325-32.

November 2.

n.2, pp 89-92.

in keratoplasty. Discovery medicine. Nov;10 (54):452-61

Hill R. (1976). The corneas need to breathe. *Int Contact Lens Clin*; 3: 60-1.

infectious keratopaty : architecture of tissue determins the microbial propagation.

vascularization. An ideal size is 7,5 mm. Smaller sizes would give rise to astigmatism due to subsequent tissue tension. Excision of donor tissue consists of trephining the corneo-scleral button previously excised from the cadaver. Trephination (cutting) is performed with the donor graft endothelial side up in a concave Teflon block. The donor button is to be 0,5 mm larger than the planned recipient opening.

 For less complications, it is main important also to verify excision of recipient tissue, the size of pupils (miosed pre-keratoplasty to avoid injuring the lens and causing cataract), the sterilization process for trephination if is manual, motorized, or vacuum trephine, rapid decompression of the eye is to be avoided. Partial thickness cut is hence performed first, than full-thickness trephination is performed. Four cardinal interrupted sutures are applied at 12, 3, 6, and 9 o'clock respectively. Interrupted or running sutures are then performed. The anterior chamber volume is reformed by injecting Balanced Salt Solution (BSS). Another post-keratoplasty care treatment is: the use of topical steroids QID and Mydriatic solution BID instilled in the operated eye for the next four weeks. Topical steroids should be continued QD for 6 months, the QOD for another 6 months. Early complications include flat anterior chamber, persistent epithelial defects, and infection. Late complications include glaucoma, astigmatism, late wound separation, cystoid macular edema, and recurrence of the initial disease in the donor graft. Graft failure: Early: Cloudiness of the cornea from the first post-op day. It is usually caused by defective donor endothelium or trauma during surgery. Late: Usually the result of immune graft rejection. 50 % occur in the first 6 months, and the majority occurs in the first year post-operatory.

It is equally important to know the history of allergies, systemic diseases and associations that can bring further complications in the recipient and ideally have the donor immunologic and systemic associations to verify their biocompatibility and immunological affinities between donor and receptor of the cornea. Another important issue is to verify early signs of rejection and microbiological differential diagnosis like infiltrates, edema, pain, to respond in time with the antibiotic, antifungal or antiviral indicated as appropriate in each case. Only in this way, it contributes to the success of a surgery that is vital to regain the vision and have no regrets later of rejection and putting at risk the integrity of visual health. Also, join efforts between expert around the world may compromise efforts against the rejection and the injury to prevent any complications and also to find new treatment options for actualize protocols, find new options and improve new technologies applied for medicine, engineering and new applications sciences for better quality life of patients.

## **6. Acknowledgment**

To my friends: Doctor Emilio Méndez MD., Ophthalmologist, cornea specialist at Colombia, and Dr. Juliana Tirado MD., Ophthalmologist for their dedication to save corneas and contribute to research on ocular infections in our Country and to my co-workers of Research Group "Salud Visual" at Fundación Universitaria del Area Andina Pereira and our Institutional Research Center.

#### **7. References**

Barraquer, R.I., Alvarez, J.P, Fischer A. Martinez G., Prevención y tratamiento del asitigmatismo en queratoplastia penetrante. Annals d'oftalmologia 2002;10(2):69- 80.

vascularization. An ideal size is 7,5 mm. Smaller sizes would give rise to astigmatism due to subsequent tissue tension. Excision of donor tissue consists of trephining the corneo-scleral button previously excised from the cadaver. Trephination (cutting) is performed with the donor graft endothelial side up in a concave Teflon block. The donor button is to be 0,5 mm

 For less complications, it is main important also to verify excision of recipient tissue, the size of pupils (miosed pre-keratoplasty to avoid injuring the lens and causing cataract), the sterilization process for trephination if is manual, motorized, or vacuum trephine, rapid decompression of the eye is to be avoided. Partial thickness cut is hence performed first, than full-thickness trephination is performed. Four cardinal interrupted sutures are applied at 12, 3, 6, and 9 o'clock respectively. Interrupted or running sutures are then performed. The anterior chamber volume is reformed by injecting Balanced Salt Solution (BSS). Another post-keratoplasty care treatment is: the use of topical steroids QID and Mydriatic solution BID instilled in the operated eye for the next four weeks. Topical steroids should be continued QD for 6 months, the QOD for another 6 months. Early complications include flat anterior chamber, persistent epithelial defects, and infection. Late complications include glaucoma, astigmatism, late wound separation, cystoid macular edema, and recurrence of the initial disease in the donor graft. Graft failure: Early: Cloudiness of the cornea from the first post-op day. It is usually caused by defective donor endothelium or trauma during surgery. Late: Usually the result of immune graft rejection. 50 % occur in the first 6 months,

It is equally important to know the history of allergies, systemic diseases and associations that can bring further complications in the recipient and ideally have the donor immunologic and systemic associations to verify their biocompatibility and immunological affinities between donor and receptor of the cornea. Another important issue is to verify early signs of rejection and microbiological differential diagnosis like infiltrates, edema, pain, to respond in time with the antibiotic, antifungal or antiviral indicated as appropriate in each case. Only in this way, it contributes to the success of a surgery that is vital to regain the vision and have no regrets later of rejection and putting at risk the integrity of visual health. Also, join efforts between expert around the world may compromise efforts against the rejection and the injury to prevent any complications and also to find new treatment options for actualize protocols, find new options and improve new technologies applied for medicine, engineering and new applications sciences for better quality life of patients.

To my friends: Doctor Emilio Méndez MD., Ophthalmologist, cornea specialist at Colombia, and Dr. Juliana Tirado MD., Ophthalmologist for their dedication to save corneas and contribute to research on ocular infections in our Country and to my co-workers of Research Group "Salud Visual" at Fundación Universitaria del Area Andina Pereira and our

Barraquer, R.I., Alvarez, J.P, Fischer A. Martinez G., Prevención y tratamiento del

asitigmatismo en queratoplastia penetrante. Annals d'oftalmologia 2002;10(2):69-

larger than the planned recipient opening.

and the majority occurs in the first year post-operatory.

**6. Acknowledgment** 

Institutional Research Center.

**7. References** 

80.


**8** 

*Italy*

**Diagnosis and Treatment of a Rare** 

 **Retained Descemet's Membrane** 

Roberto Ceccuzzi, Gabriella Ricciardelli, Annita Fiorentino, Meri Tasellari, Giovanni Furiosi and Paolo Emilio Bianchi

**Complication After Penetrating Keratoplasty:** 

*University of Pavia, Ophthalmic Department Foundation IRCCS San Matteo Pavia* 

Retention of the host's Descemet's membrane is a complication which can occur during the course of a penetrating keratoplasty and which eventually leads to loss of graft clarity by clouding or by coming into contact with the graft endothelium. The retained Descemet's membrane can compromise endothelial tissue by contact injury or by limiting diffusion of

In our study we discuss the pathogenesis, diagnosis and treatment of this complication. In

Corneal grafting techniques date back to the latter part of the 19th century and the earlier part of the 20th century as exemplified by pioneer ophthalmologists such as Reisinger, von

Penetrating Keratoplasty refers to the full thickness replacement of a diseased cornea with a healthy donor tissue. This technique may be used or to provide tectonic support in case of corneal thinning and perforation, either in case of keratoconus, bullous keratopathy, corneal dystrophies and degeneration, trauma or any other causes of corneal decompensation. Because of the "open sky" exposure of the intraocular contents during this kind of surgery, IOP control is an important step to avoid the risk of intraoperative expulsive choroidal haemorrhage. Using a calliper the horizontal and vertical diameters of the recipient's cornea are measured and the size of the graft is determined base on pathology and clinical judgement. Traditionally is used a size disparity in which the donor tissue is 0.25 mm larger than that of the recipient. The centre of the recipient cornea is marked so as the periphery with a radial keratotomy marker stained with ink. Then, while preparing the donor tissue punching the corneal button, the recipient cornea is cut by a trephine and the trephination is stopped as soon as aqueous egress shows the anterior chamber has been entered. Suction is released and the viscoelastic is then injected; the recipient button is excised using forceps and corneal scissors. Then the donor button is placed over the recipient bed and sutured in

addition we report some our cases treated with three different approaches.

**1. Introduction** 

aqueous humour nutrients.

Hippel and Elsching.

**2. Corneal transplant techniques** 

Mertz G. (1980). Overnight swelling of the living human cornea. *J Am Optom Assoc*; 51: 211-4.

