REJECTION IN PEDIATRIC CORNEAL GRAFTS
Anita Panda
Rakhi Kusumesh
Murugesan Vanathi
Tushar Agarwal
S Khokhar
Cornea and Refractive Surgery Services
Dr Rajendra Prasad Centre for Ophthalmic Sciences
All India Institute of Medical Sciences, New Delhi, India
The authors have no financial interest in the subject matter of this poster.
INTRODUCTION


Congenital corneal opacities are important causes of pediatric corneal
blindness.
Pediatric keratoplasty 1,2 is technically demanding because of wide
range of challenges preoperatively, intraoperatively, and postoperatively.
Preoperative
•Amblyopia
•Ocular pathology
•Severity of disease
Intraoperative
Postoperative
•Small-sized globe
•Low scleral rigidity
•Positive vitreous
pressure
•Increased fibrin reaction
•Increased elasticity of
cornea
•Repeated examinations
under anesthesia (EUA)
•Postoperative
inflammation
•Amblyopia therapy
•Secondary glaucoma
•Increased risk of
rejection
1 Vanathi M, Panda A ,Vengayil S. Pediatric Keratoplasty. Surv Ophthalmol 54:245--271, 2009
2 Huang et al. Primary Pediatric Keratoplasty: Indications and Outcomes. Cornea 2009;28:1003–1008
INTRODUCTION CONTD…..
3.

Graft rejection is the most frequent cause for graft failure in pediatric
keratoplasty.

Pediatric corneal transplantation has an increased rejection rate
because of the more active immune system in younger patients.3

In infants with an amplified inflammatory response, graft rejection can
occur rapidly and be less responsive to treatment.

Early symptoms of graft rejection, reduce visual acuity and ocular
discomfort, cannot be communicated resulting in a delay in the diagnosis
and treatment

Well-established graft rejection in children is usually irreversible.
Alldrege C, Krachmer JC. Clinical types of corneal transplant rejection. Arch Ophthalmol. 1981 ;99 : 599--604
PURPOSE

To study the incidence of graft rejection in
our series of pediatric corneal grafts.
METHODS

Retrospective analysis of case records of keratoplasty in children < 12
years between 2006 and 2009 with a minimum follow-up of 4 months

The parameters analyzed include: demographic profile, indication of
surgery, surgical details, donor details, graft outcome, and complications.

Ophthalmic evaluation included : visual acuity , slit-lamp biomicroscopic
examination (in possible cases), intraocular pressure. Examination under
general anesthesia was done whenever required. Ultrasound B scan was
used to evaluate the posterior segment.
METHODS CONTD……





Penetrating keratoplasty was performed in all cases under
general anesthesia by using standard techniques.
The mean host cut was 7.33±1.22(SD) mm and mean donor
size was 7.80±1.33 (SD)mm . A host–graft disparity of 0.25–
1.0 mm was used.
Synechiolysis, anterior vitrectomy, and cataract extraction with
or without intraocular lens implantation were done wherever
required.
Topical steroid and antibiotic eyedrops were used. Topical
steroids are given more frequently in the initial postoperative
period and gradually tapered and changed to less potent
steroids such as fluoromethalone in 3--6 months.Cycloplegics
were used whenever required.
EUA was performed in early postoperative period and follow up.
Peters anomaly
RESULT
Indication for keratoplasty
n (74)
%

Penetrating keratoplasty had
been performed in 74 eyes of 74
children younger than 12 years of
age.

45 male and 29 female.

Mean age at the time of surgery
5.64 ± 4.24 years (range 2
months – 12 years).

Average follow up of 14.05 ±
10.68 months.(4-48 months)
Congenital
CHED
8
10.6%
Non-CHED
9
12%
Congenital glaucoma
12
16%
Acquired nontraumatic
Perforated corneal ulcer
14
18.9%
Post keratomalacia
corneoiridic scar
5
6.75%
Post keratitis corneo-iridic
scar
21
28.3%
Post traumatic
1
1.35%
Regraft
4
5.40%
POSTOPERATIVE COMPLICATIONS
Complications
No of
eyes
(n=74)
n(%)
Persistent
epithelial defect
7
9.5%
Graft rejection
9
12.2%
Graft dehiscence
2
2.70%
Glaucoma
6
8.10%
Cataract
3
4.05%
Graft infection
8
10.8%
(worsening of
glaucoma/post PK
glaucoma)

In the 74 eyes undergoing
keratoplasty, graft rejection
(12.2%) was the most common
complication followed by graft
infection(10.8%) .
Incidence of graft rejection
Diagnosis
Graft
rejection(n= 9)
%
Graft
survived
Acquired nontraumatic 4
44.4%
2
CHED
3
33.3%
1
Congenital glaucoma
1
11.1%
0
Regraft
1
11.1%
0

The most
common reason
for graft failure
was graft
infection(42.1%,
n=8) followed by
irreversible
rejection (31.5%,
n=6).

Episodes of
Graft rejection
higher in
acquired
nontraumatic
cases(44.4%),
followed by
CHED(33.3%).
DISCUSSION

Corneal grafting in children is different from that in adults
because of morphologic and functional aspects, and these
differences are reflected in the overall outcome of the surgery.

In our study, nearly half of the patients (54.1%) belonged to the
acquired nontraumatic group and healed infection was the
most common indication for keratoplasty. This is in contrast
with the majority of published reports, in which congenital
indications contribute a significantly greater proportion.4,5

The reported percentages of graft rejection in pediatric
keratroplasty vary between 22%7 and 43.4%4. In this study
12.2% cases of graft rejection found.
4. Aasuri MK, Prashant G, Gokhle N, et al. Penetrating keratoplasty in children. Cornea 2000;19:140–4.
5.Dada T, Sharma N, Vajpayee RB. Indications for pediatric keratoplasty in India. Cornea 1999;18:296–8.
DISCUSSION CONTD……



31.5%(n=6) of graft failure were related to graft rejection
whereas Stulting et al6 reported 11% of graft failures to be
related to allograft rejections.
Rejection was reversible in only 33.3% of episodes, showing a
much lower reversal rate in pediatric grafts compared to that of
50--78% in adult grafts3.Reasons are: 1)delay in the diagnosis
(can’t communicate) 2) delay in treatment (delay in reaching
center) 3) examination required anaesthesia 4) large volume of
patients.
Successful penetrating keratoplasty in children requires careful
preoperative evaluation and selection of patients follow-up by
well-motivated parents, an expert corneal transplant surgeon,
and a devoted pediatric ophthalmologist.
6.Stulting RD, Sumers KD, Cavanagh HD. Penetrating keratoplasty in children. Ophthalmology. 1984;91:1222—30
7.Vajpayee RB, Ray M, Panda A, et al. Risk factors for pediatric presumed microbial Keratitis: a case control study.
Cornea. 1999;18:565--9