. Purpose: To describe a modified graft‐over‐host (MGOH) surgical technique which was used to prevent serious complications in cases of positive vitreal pressure during penetrating keratoplasty (PKP) and to compare the endothelial cell density (ECD) loss and clinical outcome between eyes undergoing MGOH or standard PKP. Methods: In the proposed MGOH technique, the donor graft is sutured over the recipient cornea as soon as signs of positive pressure are noticed, even before cutting the recipient cornea, and the surgery is continued by consecutive cutting of the recipient and continuous suturing of the donor cornea, quadrant by quadrant. Donor grafts were prospectively followed up for the graft clarity, ECD loss and the amount of astigmatism. Results: Of 220 cases scheduled for standard PKP in years 2009–2011, eight were operated by MGOH technique. Despite the fact that the donor cornea is situated over the recipient almost throughout the whole MGOH procedure, the ECD loss is equal between eyes operated on by MGOH technique and standard PKP, and none of the grafts had primary graft failure. The only disadvantage was an increased amount of astigmatism that was not as significant once the sutures were taken out. Conclusion: Modified graft‐over‐host technique seems to be a safe and effective method to prevent complications during PKP complicated by positive vitreal pressure.
Purpose Herpetic keratitis may lead to a significant corneal scaring and loss of vision which often leads to surgical treatment, which can be both penetrating (PKP) and deep anterior lamellar keratoplasty (DALK). However, the survival of corneal grafts is hampered by the presence of neovascularization (NV) and possible recurrence of herpetic disease. In our prospective study we have used bevacizumab treatment at the end of surgery, aiming to decrease corneal NV,and consequently to increase graft survival rate. Methods Twelve high‐risk eyes undergoing PKP due to post‐herpetic corneal scar were progressively followed up for 17.54 months (range 6‐24). There were 7 females and 5 males of average age 51 and 44.28 years, respectively. All surgeries were ended by subconjunctival bevacizumab injection (25 mg/ml) under the NV. Grafts were prospectively examined for their clearance, presence of NV and endothelial cells density (ECD) loss. Results At the end of follow‐up 11 out of 12 (91.7%) of corneal grafts remained clear; corneal NV reduction was found in all eyes and ECD loss at 24 months was 26.63%. Two out of 12 (16.6%) of patients had herpetic recurrence in their graft, which was successfully treated with systemic acyclovir. Conclusion Subconjunctival bevacizumab may offer an adjunctive measure during surgical treatment of post‐herpetic corneal scars. This might be explained by suppression of the angiogenic potential mediated by VEGF in such patients.
Purpose We evaluated the effect of bevacizumab treatment in a prospective 2 year follow‐up study of 50 [bdquo]high risk“ eyes undergoing penetrating keratoplasty (PKP). Methods Hihg‐risk diseases were: 2 Stevens Johnson syndrome (SJS), 6 chemical burns, 9 post‐herpetic, 16 other vascularized scars, 13 rejected grafts and 4 ulcers. PKP was performed in all 50 patients; combined with other procedures as follows: 12 “triple” procedures (PKP + cataract),11 PKP+ amniotic membrane transplantation (AMT),4 triple+AMT+ transplantation of limbal cells (LCAT). Subconjunctival injection of 25 mg/ml of bevacizumab was given to all patients at the end of surgery. Recipient corneal buttons were dissected into 3 corneal layers, stored in media for 24 hours at 37oC, and frozen till detection of VEGF quantity by immunoassay (ELISA). Corneal buttons from patients with non‐inflammatory diseases served as controls. Results Decrease of corneal neovascularization was observed in 88% of patients who received bevacizumab, and 86% of grafts remained clear. Mean best corrected visual acuity had statistically significant increase in all groups from 0.03 to 0.5, with the poorest visual outcome in SJS patients. Average postoperative astigmatism was ‐4,83 Dcyl. Average endothelial cell loss was 22.83% after one, and 31.97% after two years (similar in all groups). Secreted VEGF was significantly higher in high risk cases (2436.7 pg/ml) as compared to non‐inflamed corneas (504.7 pg/ml). Conclusion Combined “anti‐inflammatory“approach of AMT, LCAT and bevacizumab may significantly improve corneal graft survival rate in [bdquo]high‐risk“ eyes.
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