Transcript Post Keratoplasty Atopic Sclerokeratitis after Deep Anterior Lamellar

Post Keratoplasty Atopic Sclerokeratitis (PKAS)
after
Deep Anterior Lamellar Keratoplasty (DALK).
Sharmina R Khan
William H Ayliffe
Mayday University Hospital, Croydon, London, UK.
April 7-9, 2010
Boston, MA, USA
The authors have no financial interest in the subject matter of this presentation.
Introduction
• PKAS is a severe (non-rejection) inflammation that infrequently occurs
following keratoplasty.
• A retrospective Japanese series found 6 eyes developed PKAS, of 29 with
atopic dermatitis, of a total 247 eyes with keratoconus that underwent a
keratoplasty procedure between May 2000 and December 2005 (1).
• Clinical features:
- Occurs in the early post operative period within the first few weeks.
- Diffuse anterior scleritis.
- Loosening of sutures, persistent epithelial defects and graft melting.
• Differential diagnosis:
• Acute epithelial rejection
• Microbial keratitis (staphylococcal)
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Tomita M, Shimmura S, Tsubota K, Shimazaki J. Postkeratoplasty Atopic Sclerokeratitis in Keratoconus Patients. Ophthalmology, 2008,
May, 115 (5); 851-856.
Sharmina R Khan, William H Ayliffe.
Introduction
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Risk factors for PKAS:
i) Atopic dermatitis/ Allergic eye disease (2) /Asthma (1)
ii) Active blepharitis (1)
iii) Corneal neovascularisation (1)
iv) Elevated serum IgE (2)
Treatment includes early loose suture removal +/- resuturing, systemic
Prednisolone +/- immunosuppressant. We describe our experience using po
Cyclosporin and po Tacrolimus.
Prognosis can be excellent if treatment is timely. However, there is significant
co-morbidity associated with the use of immunosuppressants.
Purpose of Presentation:
We describe four cases of PKAS following DALK which has been described once
before (3), all other reports have been following penetrating keratoplasty (PK).
Daniell MD, Dart JKG, Lightman S Use of cyclosporin in the treatment of steroid resistant post-keratoplasty atopic sclerokeratitis. Br J
Ophthalmol 2001;85:91–92.
Lyons CJ, Dart JKG, Aclimandos WA, et al. Scleritis after keratoplasty in atopy. Ophthalmology 1990;97:729–33.
Sharmina R Khan, William H Ayliffe.
Case 1: 34 year old woman
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Keratoconus,severe eczema, atopic
keratoconjunctivitis (AKC).
Right DALK (donor 8.25mm, host 8.0mm)
10/0 nylon continuous).
Preoperatively g. Fluoromethalone and
g. Sodium Cromoglycate
1 week later multiple suture related
infiltrates developed.
po Prednisolone 30mg started and tapered
rapidly
3 weeks later loose sutures.
Inferiorly necrotic host cornea (arrow).
Graft re-sutured with interrupted 10/0
nylon.
po Prednisolone 40mg started and tapered
over 6 months.
Loose sutures without inflammatory
episodes were removed as required.
BCVA RE 6/9
Sharmina R Khan, William H Ayliffe.
Case 2: 14 year old boy
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Keratoconus, atopic dermatitis.
Right DALK (donor 8.25mm donor, host 8.00mm, 10/0 nylon interrupted).
Pre-operatively g. Lodoxamide
6 weeks post-op developed a graft epithelial defect followed by rapid
stromal necrosis that did not respond to topical steroids and po Acyclovir.
8 weeks later right tectonic DALK (lyophilised donor) interrupted 10/0
nylon with po Acyclovir prophylaxis.
3/7 post-op developed loose sutures and non-necrotising anterior scleritis
that persisted for 10/52.
po Prednisolone 30mg tapered over 6 months.
Repeat DALK due to early suture loosening.
Left DALK carried out under po Prednisolone cover and tapered over 6
months with an uneventful post-op course.
BCVA RE 6/9
BCVA LE 6/9
Sharmina R Khan, William H Ayliffe.
Case 3: 29 year old man
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Keratoconus, severe atopic dermatitis, AKC.
Left DALK (donor 8.0mm, host 8.25mm 10/0
continuous nylon).
Pre-operatively g. Lodoxamide TDS and
g. Fluoromethalone TDS LE
3 days post-op developed loose sutures,
epithelial defect and non-necrotosing
anterior scleritis.
3 weeks later epithelial rejection line noted
& po Prednisolone 60mg OD started
Inflammation continued resulting in host
melting.
po Cyclosporin 150mg BD started and
tapered over 6 months.
Right DALK was carried out with po
Tacrolimus prophylaxis (commenced by
dermatologist) post-op course was
uneventful.
BCVA RE 6/6 BCVA LE 6/12 (stromal fibrosis
2⁰ recurrent shield ulcers).
Sharmina R Khan, William H Ayliffe.
Case 4: 18 year old woman
• Keratoconus, asthma, eczema, hayfever.
• Right DALK (donor 8.0mm, host 8.25mm, 10/0 nylon continuous).
• po Prednisolone 40mg OD and po Tacrolimus 2mg OD commenced 1/52
pre-op .
• po Prednisolone tapered over 6/52 post op.
• po Tacrolimus stopped 10/52 post op.
• 1/12 later she had an exacerbation of eczema that required po
Prednisolone and oral antibiotics.
• Concomitantly developed sectoral anterior scleritis, loosening of sutures,
deep corneal neovascularisation.
• po Tacrolimus resumed and continuous suture removed.
Sharmina R Khan, William H Ayliffe.
Case 4: 18 year old woman
• 4/12 later developed epithelial
rejection which responded to topical
treatment.
• Deep corneal interface
vascularisation and fibrosis (arrows)
progressed despite being on
po Tacrolimus 2mg BD and
po Prednisolone 7.5mg OD and
g. Predsol 0.5% PF BD RE
• Compliance with medication was a
problem throughout.
• BCVA RE 6/12
Sharmina R Khan, William H Ayliffe.
Discussion
• Pre-operative management
• Treat blepharitis and AKC as an atopic ocular
surface is at increased risk of microbial
(Staphylococcus aureus) keratitis.
• Plan surgery when atopic disease is at its most
quiescent, so that you are operating on a
minimally inflamed eye.
Sharmina R Khan, William H Ayliffe.
Discussion
• Intra-operative management
• Use interrupted sutures.
• Post-operative management
• In a DALK, PKAS may be less acutely
destructive and more difficult to diagnose
than in a PK.
Sharmina R Khan, William H Ayliffe.
Conclusion
• Early recognition is important as PKAS responds
well to prompt suture management and
systemic treatment.
• We propose:
i) Plan DALK instead of a PK in such high risk
cases due to requirements for repeat grafting.
ii) Use of systemic immunosuppressant as a
prophylactic measure if PKAS has occurred in
the first eye.
Sharmina R Khan, William H Ayliffe.