Penetrating Keratoplasty After Ocular Trauma Gregory S. Doren, M.D., Elisabeth J. Cohen, M.D., Steven E. Brady, M.D., Juan J. Arentsen, M.D., and Peter R. Laibson, M.D. We reviewed the records of 41 patients who underwent penetrating keratoplasty for a corneal opacity caused by trauma between Jan. 1, 1983, and Dec. 31, 1988. Most of the patients were young males whose average age was 35 years. Common tools accounted for many injuries (14 of 41,34%). Sixteen injuries (39%) were work-related. Thirty-six patients (88%) had corneal scars from a perforating injury, four patients (10%) had corneal edema, and one patient (2%) required emergency penetrating keratoplasty for extensive tissue loss. Of the 39 patients with one year of follow-up, 31 (82%) maintained clear corneal grafts. Rejection occurred in nine of 39 patients (23%) and only three (33%) of the rejections resolved. Visual outcome was favorable with 20 patients (51 %) attaining best-corrected postoperative visual acuity of 20/20 to 20/40, nine patients (23%) attaining visual acuity of 20/50 to 20/ 100, and ten patients (26%) attaining visual acuity of 20/200 or worse. Preoperative retinal disease (six of 39, 15%), astigmatic errors (five of 39, 13%), graft failures (four of 39, 10%), and postoperative glaucoma (12 of 39, 31%) adversely influenced the outcome. Although the prevalence of postoperative complications is relatively high, good visual results can be obtained in patients who undergo penetrating keratoplasty after ocular trauma. OCULAR TRAUMA is a frequent cause of unilateral blindness.!" For those patients who suffer serious anterior segment injuries, final visual
Accepted for publication July 24, 1990. From the Cornea Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania. This study was supported in part by the Corneal Research Fund and Lions Eye Bank of the Delaware Valley. This study was presented at the Wills Eye Hospital Conference, Philadelphia, Pennsylvania on March 31, 1990. Reprint requests to Elisabeth J. Cohen, M.D., Cornea Service, Wills Eye Hospital, 9th & Walnut Sts., Philadelphia, PA 19107.
acuity is often reduced by corneal scarring and irregularity. Often, rigid contact lenses correct irregular astigmatism and allow these patients to attain useful vision. For some individuals, however, corneal scars are dense and central enough to impair vision. For these patients, corneal transplantation can improve vision.!" Little data exist regarding the outcome for patients who undergo penetrating keratoplasty after trauma, because trauma is an uncommon indication for penetrating keratoplasty.v" Previous studies have reported the high prevalence of postoperative complications, such as glaucoma and graft rejecnon.v-" We analyzed our recent experience with corneal transplantation in patients with ocular trauma.
Patients and Methods We reviewed the records of all our patients who underwent penetrating keratoplasty for a trauma-related corneal opacity between Jan. 1, 1983, and Dec. 31, 1988. Factors analyzed included age, sex, race, associated ocular surgery or complications, the status of the lens and retina, best-corrected preoperative and postoperative visual acuity, preoperative and postoperative intraocular pressures, and the graft clarity. Con tact lens trials in addition to all refractive and keratometric data were evaluated. We also examined the source of injury, its setting (that is, work or home), and the time from initial injury to penetrating keratoplasty. Snellen visual acuities were categorized into three main groups: good visual acuity of 20/20 to 20/40, moderate visual acuity of 20/50 to 20/100, and poor visual acuity of 20/200 or worse. Best-corrected visual acuity was used for statistical evaluation. Increased intraocular pressure was defined as an intraocular pressure greater than 21 mm Hg, which required either medical or surgical treatment. Retinal status was determined clinically, with intravenous fluorescein angiography used when necessary for diagnosis.
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With regard to postoperative data, only those patients with at least one year of follow-up or those believed to be at a visual end point (for example, 20/200 visual acuity in a patient with a macular hole) were used for statistical analysis. Statistical evaluation was by chi-square tests with Fisher's variant as required by sample size. Penetrating keratoplasty was performed with a 0.2-mm oversized corneal donor for phakic eyes and a 0.5-mm oversized donor for aphakic and pseudophakic eyes in most cases. Either interrupted 10-0 nylon suture, a continuous 10-0 nylon running suture, or a combined technique was used for closure depending on the amount of vascularization and surgeon preference. Mechanical vitrectomy was performed when there was vitreous in the anterior chamber at the time of surgery. When cataract surgery was required, the extracapsular method was performed in most cases, with or without intraocular lens implantation. An all-polymethylmethacrylate, open-looped anterior chamber lens was inserted in two patients secondarily. Peripheral anterior synechiae and posterior synechiae were lysed at the time of surgery. Residual cortex from previous operations or inflammatory membranes in the visual axis were also removed when encountered.I-" In two of our patients, a rotating keratoplasty was performed for peripheral corneal scars."
Results Of the 41 patients, 33 (80%) had a corneal scar as the surgical indication, four (10%) had corneal edema secondary to trauma, three (7%) had a corneal scar and cataract, and one patient (2%) had such severe tissue loss that corneal transplantation was required to close the eye. The average age of the patients was 35 years (range, 1 to 80 years). There were 35 males and six females. The right eye was affected in 16 patients and the left eye was affected in 23 patients. Most of our patients were young males with left eyes more commonly affected. The cause of trauma was tools in 14 patients (34%), motor vehicle accidents in nine (22%), glass fragments in seven (17%), fights in four (10%), war injuries in two (5%), and miscellaneous sources in five (12%). The miscellaneous category was composed of injuries from a fishhook, piece of concrete, plank, and two unknown projectiles. Sixteen (39%) of the injuries
were work-related, most of these from tools. None of our patients with work-related injuries wore safety spectacles. Twenty-eight (68%) of our patients had aphakia secondary to their initial injury. The average time interval from the initial injury to penetrating keratoplasty was seven years (range, one day to more than 50 years). The procedures performed were penetrating keratoplasty alone in 27 patients (66%); penetrating keratoplasty with lysis of peripheral anterior synechiae in seven (17%); penetrating keratoplasty with cataract extraction with intraocular lens implantation in two (5%) and without intraocular lens implantation in one (2 %); penetrating keratoplasty with secondary intraocular lens implantation in two (5%); and rotary penetrating keratoplasty in two (5%). Four patients received intraocular lenses at the time of their surgery, two in association with their cataract removal and penetrating keratoplasty, and two secondarily. There was one case of postoperative endophthalmitis caused by streptococcus, which resulted eventually in enucleation. The average length of follow-up was 32 months (range, one to 72 months). Of the 41 patients, 37 had at least one year of follow-up. Two additional patients with poor vision caused by retinal disease were thought to be at a visual end point with less than one year of follow-up. It is these 39 patients who comprise the database for analysis of postoperative data. The remaining two patients had only one and three months of follow-up and were not included in the analysis. Corneal graft clarity was achieved in most of our patients (32 of 39, 82%). Those patients younger than 18 years old, as a group, had higher rates of graft failure with five of eight (62%) clear. There was a fairly high rate of rejection. Not including the two cases of rotating keratoplasty and the one case of early endophthalmitis, nine patients (25%) had at least one episode of rejection. Only one third of these resolved with medical treatment. The average onset of a rejection episode leading to graft failure was 22 months postoperatively (range, seven to 36 months). Preoperatively, two of 39 patients (5%) had visual acuity of 20/20 to 20/40, nine (23%) had visual acuity of 20/50 to 20/100, and 28 (72%) had visual acuity of 20/200 or worse. Of the five patients younger than 10 years of age, all had preoperative visual acuity of 20/200 or worse. Postoperatively, 20 of 39 patients (51 %)
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had visual acuity of 20/20 to 20/40, nine (23%) had visual acuity of 20/50 to 20/100, and ten (26%) had visual acuity of 20/200 or worse. Of the five patients younger than 10 years of age, three (60%) had visual acuity of 20/20 to 20/ 40, one (20%) had visual acuity of 20/50 to 20/100, and one (20%) had visual acuity of 20/200 or worse. There was no correlation between final visual outcome and a patient's age, sex, race, type of injury, or whether vitrectomy was performed at the time of surgery. Patients referred from the Retina Service had worse final visual acuity because of their previous retinal disease. For those 19 patients with final visual acuity worse than 20/40, retinal disease (including retinal detachment, cystoid macular edema, and diabetic retinopathy) was the reason for poor vision in six patients (32%), astigmatic or refractive errors in five (26%), cornea in four (21 %), glaucoma or optic neuropathy in two (11 %), amblyopia in one (5%), and endophthalmitis in one (5%). One of the five patients younger than 10 years of age had amblyopia accounting for final visual acuity less than 20/40. Postoperative complications included increased intraocular pressure in 12 patients (31 %), retinal detachment in three (8%), traumatic wound dehiscence in three (8%), suture abscess in two (5%), endophthalmitis in one (2.5%), and no complications in 18 (46%). There was no statistically significant difference regarding increased intraocular pressure when comparing aphakic and pseudophakic eyes to phakic eyes. Medications were able to control intraocular pressures in most patients (nine of 12,75%). Three patients required cyclodestructive procedures to control intraocular pressure. Postoperatively, over one half of the patients in the 20/20 to 20/40 visual acuity group required contact lenses. Three of these 12 patients chose to not wear their lenses.
Discussion We were able to achieve excellent visual results (20/20 to 20/40) in 51 % of our patients who underwent penetrating keratoplasty after ocular trauma. Many of those who had visual acuity of less than 20/40 had posterior segment causes for their poor vision or had uncorrected irregular residual astigmatism. Because the requirement for inclusion in our study was one
year of follow-up, many of our patients with grafts had not been visually rehabilitated completely. We expect that this subgroup of patients with residual astigmatic error may attain improved visual acuity. We think that the prognosis for penetrating keratoplasty is favorable, especially if the effects of the initial trauma are localized to the anterior segment. Given the varied nature of ocular trauma, each patient's clinical situation is unique. Our results are favorable when compared to previous studies" and similar to othersv' with regard to visual outcome and graft survival. Patients who have poor prognoses because of posterior segment abnormalities may be advised not to undergo penetrating keratoplasty. We found graft rejections to be frequent and resistant to medical treatment. Neither result is surprising, given the young age of our patients and the often vascularized nature of the corneal scarring. These patients are followed up frequently to observe any early signs of rejection. Increased intraocular pressure was a frequent problem after surgery, increasing from four patients (10%) preoperatively to a total of 12 patients (32%) postoperatively. The combination of anterior segment trauma, associated angle injury, residual peripheral anterior synechiae, and aphakia all contribute to a high prevalence of glaucoma after keratoplasty. This association in patients with trauma who underwent keratoplasty has been noted in previous series.3.4.6 The addition of YAG cyclophotocoagulation and setons offers more therapeutic options." Many of our patients with irregular astigmatism tried contact lenses before undergoing surgery and failed to attain good vision or comfort. We think a trial of contact lens wear should be attempted before performing corneal transplantation, because many patients can attain surprisingly good visual acuity when their irregular astigmatism is treated, which eliminates the need for surgery. It is also important to tell patients that contact lens wear may be necessary to attain the best visual acuity postoperatively and to correct any residual astigmatism and aphakia. Of our 17 patients who required contact lenses postoperatively, only two patients were unable to wear the lenses. However, three patients who had no difficulty wearing the contact lenses chose not to use them. Their uncorrected eyes helped them little in their day-to-day activities. Younger patients tended to fare worse in our
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study, with a higher percentage of graft rejection. In children younger than 10 years of age, an added concern regarding final visual acuity is amblyopia. In unilateral aphakia, the prevention of amblyopia is difficult. Coupled with corneal transplantation, that difficulty is increased. Parents should be able to take an active role in their child's treatment before the ophthalmologist recommends corneal transplantation. It is particularly important to explain in detail the difficult course ahead for parents if such surgery is performed, so they are fully aware of their responsibilities in treatment. Concurrent care with a pediatric ophthalmologist as well as an experienced contact lens team is necessary for achieving optimal results. Three patients (18%) had traumatic wound dehiscence postoperatively, which suggests our patients may be an inherently trauma-prone population.v" Safety spectacles should be recommended to these patients after keratoplasty. Even though many of these patients suffered marked disorganization of the anterior segment, angle damage, cataracts, and posterior segment injury, good results were achieved with penetrating keratoplasty in many patients. Meticulous attention to management of the vitreous intraoperatively and close postoperative monitoring of patients, especially children, is essential to minimizing complications. Increased intraocular pressure and retinal disease persist as the most difficult postoperative problems to treat. Finally, in our study, a high percentage of work-related ocular injuries might have been prevented if safety goggles for workers at risk for injury were worn routinely.
References 1. Schein, 0., Hibberd, P., Shingleton, B" Kunzeiler, T., Frambach, D., Seddon, J., Fontan, N., and Vinger, P.: The spectrum and burden of ocular injury. Ophthalmology 95:300,1988. 2. Maltzman, B., Pruzon, H., and Mund, M.: A survey of ocular trauma. Surv. Ophthalmol. 21:285, 1976. 3. Robinson, L.: Keratoplasty following anterior segment trauma. Aust. J. Ophthalmol. 9:59, 1981. 4. Severin, M.: Keratoplastik nach perforiender verletzung. Fortschr. Ophthalmol. 81:207, 1984. 5. Brady, S. E., Rapuano, C. J., Arentsen, J. J., Cohen, E. Land Laibson, P, R.: Clinical indications for and procedures associated with penetrating keratoplasty, 1983-1988. Am. J. Ophthalmol. 108:118, 1989. 6. Sharkey, T. G., and Brown, S. I.: Transplantation of lacerated corneas. Am. J. Ophthalmol. 91:721, 1981. 7. Arentsen. Land Laibson, P.: Penetrating keratoplasty and cataract extraction. Arch. Ophthalmol. 96:75,1978. 8. Arentsen, J.: Penetrating keratoplasty techniques. Int. Ophthalmol. Clin. 29:14, 1988. 9. Bourne, W., and Brubaker, R.: A method for ipsilateral rotational autokeratoplasty. Ophthalmology 85:1312, 1978. 10. Cohen, E., Schwartz, L., Luskind, R., Parker, A., Spaeth, G., Katz, L. L Arentsen, L Wilson, R., Moster, M., and Laibson, P.: Neodymium YAG laser transscleral cyclophotocoagulation for glaucoma after penetrating keratoplasty. Ophthalmic Surg. 20:713, 1989. 11. Farley, M. K" and Pettit, T. H.: Traumatic wound dehiscence after penetrating keratoplasty. Am. J. Ophthalmol. 104:44, 1987. 12. Binder, P. S., Abel, R., [r., Polack, F. M., and Kaufman, H. E.: Keratoplasty wound separations. Am. J. Ophthalmol. 80:109, 1975.
I looked at them. Four half-moons of magnification were ground into each lens. When I raised them and looked through them, the front of the building swam like hot taffy, and AI became a small crowd. "I thought I had a problem, having to look straight ahead," I said. "What do you use them f or.?" Wallace Stegner, Angle of Repose New York, Fawcett Crest, 1971, p. 65