**8.1.2 Shallow or flat anterior chamber**

This is a generally avoidable complication with a watertight wound. At the end of the surgery is critical that we ensure the integrity of the wound. Shallow or flat anterior chamber if present, should be managed as soon as possible to avoid synechiae formation which may result in irreversible endothelial cell loss and consequently early graft failure. In our center we needed to reform the anterior chamber either with BSS or with viscoelastic substances in 1, 7 % of the cases.

Fig. 14. Flat anterior chamber in this patient with synechiae formation post therapeutic keratoplasty

### **8.1.3 Hyphema**

Surgical trauma on an eye with vessels on the surface of the iris or in the cornea can cause hyphema. Every effort should be done to prevent bleeding from the iris surface. Slight bleeding usually stops spontaneously with closure of the eye and return of adequate IOP. If the hemorrhage persists in the presence of an adequate IOP, then it may need to be

Fig. 15. Fibrine and hyphema 48 hours post keratoplasty in severe fungal ulcer (*Aspergillus flavus)* 

Therapeutic Keratoplasty for Microbial Keratitis 27

postoperative period can be performed. Alternatively, botulinum A toxin injected into the elevator muscle to induce a complete ptosis, may help reduce the severity and persistence of

The use of preservative-free medication is recommended to reduce the risk of epithelial

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

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

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

new PK to be free of infection. Time of recurrence varied between 1-42 days.

an epithelial defect.

**8.1.7 Recurrence** 

LASIK

entire graft

toxicity and corticosteroids may need to be decreased.

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 pressure, it should be immediately evacuated. Fig. 15
