COMANAGEMENT Q&A

Problems With Corneal Transplants

Edited by Paul C. Ajamian, O.D.

Question: What are some signs or symptoms that tip off the comanaging doctor that a patient is having problems with a corneal transplant?

Answer: First of all, corneal transplantation, or penetrating keratoplasty, is generally a successful surgery. Of the nearly 46,000 procedures surgeons perform each year, more than 90 percent succeed in restoring sight, the Eye Bank Association of America reports.

However, problems can arise. These include:

• Refractive errors. "In many instances, patients develop induced astigmatism from the penetrating keratoplasty, so fitting contact lenses for these patients is pretty critical for their success," says Daryl F. Mann, O.D., center director of SouthEast Eye Specialists in Chattanooga, Tenn.

General Guidelines for Removing Sutures: • All-interrupted suture: Begin removing at three months. • Combined interrupted- and- running suture: Remove the interrupted sutures at three months, the running suture at one year. • Single continuous running suture: Remove at one year. • Double running sutures: Remove one running suture at 3-6 months, the other after more than a year.

You can fit lenses when the epithelium is fully intact, usually about three months post-op. Certainly once all the sutures are out, you can fit them, explains John R. Bierly, M.D., the corneal surgeon and medical director at SouthEast.

• Healing difficulties. A broken suture can cause an infection, Dr. Bierly explains. If the patient neglects to seek medical attention, the infection can result in a suture abscess. "Refer that back to a corneal specialist immediately because it can degenerate quickly," he adds. Other healing difficulties include subepithelial scarring from the sutures or a change in astigmatism after the surgeon removes the sutures.

• Graft rejection. A red or painful eye, blurred or decreased vision can signal a graft rejection. Two other signs include keratic precipitates on the endothelium of the graft with cell and flare, and clouding of the graft, Dr. Mann explains.

The eye can reject the graft tissue anywhere from two weeks post-op to many years later, Dr. Bierly says. "One thing I tell patients: Try to remember what your eye felt like right after the surgery—usually it's red, aching, there's photophobia and some mild pain. That's very similar to the sensation of a graft rejection. If you get that, you need to seek attention immediately."

Question: What is a typical postoperative regimen for the referring O.D.? When can I expect the patient back? What types of sutures should I look for, and when do they need to be removed?

Answer: The surgeon will see the patient one-day post-op and then again at one week. If the eye seems OK at one week, then the patient would probably return to the referring O.D. after that.

The post-op therapeutic regimen begins with an antibiotic, perhaps ofloxacin (Ocuflox) or ciprofloxacin (Ciloxan) QID for one week while the eye re-epithelializes. "Store it in the refrigerator," Dr. Bierly tells patients. "You'll need it again when the sutures come out."

Also, put the patient on a corticosteroid. Dr. Bierly suggests prednisolone acetate (Pred Forte) QID for about three months. After that, consider using a weaker steroid to avoid steroid-induced glaucoma. Current research is investigating the use of cyclosporin as an imunosuppressive agent that might someday replace steroid therapy.

For phakic patients who may be at risk of developing cataract, you may want to discontinue the steroid in six months. For pseudophakic patients with no history of glaucoma, you could leave them on a drop of steroid a day, especially if they have a history of graft rejection, Dr. Bierly says. "The steroid alone, even a drop a day, may not prevent a graft rejection but it will blunt it," he adds. Normally, you wait a year to remove all the sutures.

And if the patient is seeing well, you might not remove them at all, Dr. Bierly says. Doing so could induce astigmatism.