Pediatric Corneal Transplant Surgery: Challenges for Successful Outcome

Abstract

Visual rehabilitation of pediatric corneal blinds is a major challenge to corneal transplant surgeons. Penetrating keratoplasty (PKP) is the only way to restore vision and prevent irreversible blindness due to amblyopia in children. Performing penetrating corneal grafts in children poses difficulty in evaluation, technical difficulties during surgery and problems during follow-up. Younger children do not cooperate for proper slit-lamp examination and need to be examined under general anaesthesia. In addition, the complications encountered post PKP, including allograft rejection, post PKP astigmatism and post PKP glaucoma are more frequent in pediatric group as compared to adult recipients. Even after a successful graft, the child requires rigorous treatment for amblyopia. Parents need to be counselled before surgery and possible visual outcome and chances of obtaining clear graft should be discussed.

A Review of Pediatric Corneal Transplants: Perioperative, Operative, and Postoperative Management

“…9 The role of surgical timing on visual outcomes is currently unknown, with studies showing better visual prognosis in younger patients and others citing no improvement of outcomes with earlier timing. 43,48 The rate of graft clarity has been found to be higher in patients with acquired nontraumatic opacities (70.6%), followed by congenital opacities (63.8%) and acquired traumatic opacities (54.5%). 14 In addition, eyes with acquired opacification have a greater probability ( > 70%) of remaining clear at 1 year following surgery compared with eyes with congenital opacification (60%).…”

“…11 Amblyopia therapy including patching, atropine drops, corrective glasses, or contact lens, should be initiated as soon as possible after appropriate healing of the corneal transplant is complete. 4,11,48 Cataracts Cataract formation following pediatric keratoplasty ranges from 2% to 7%; however, there is an increased incidence (18%) of cataract formation in patients who have undergone repeat surgical interventions. 4,12 Low et al 47 report a higher incidence of cataract following penetrating keratoplasty (20.5%) when compared with the rate of overall postoperative cataract formation (10.5%) in eyes that underwent penetrating keratoplasty, anterior lamellar keratoplasty, lamellar corneal patch graft and Descemet stripping automated endothelial keratoplasty.…”

“…Glaucoma drainage implant procedures may also be effective in IOP control following pediatric keratoplasty but also can pose a risk to corneal integrity by contributing to endothelial cell loss. 48 Amblyopia Amblyopia detection, prevention, and treatment are important preoperative factors in determining surgical timing and a major postoperative concern following pediatric keratoplasty. The goal of effective amblyopia management is to obtain symmetric and ageappropriate visual acuity in both eyes to ensure the development of binocular fusion.…”

“…14 This may be in part due to normal development of vision without any amblyogenic risk factors before corneal involvement. 45,48 There are less common outcomes where visual acuity may remain the same or worsen in some patients. 32,45 Anatomic success alone does not equate to good visual outcome in all patients following keratoplasty.…”

“…Treatment for glaucoma includes medical management, trabeculectomy with adjuvants, trabeculectomy. Glaucoma drainage implant procedures may also be effective in IOP control following pediatric keratoplasty but also can pose a risk to corneal integrity by contributing to endothelial cell loss 48…”