Pediatric Keratoplasty

1. Presented by:
Dr. Mohammad Abdullah Bawtag
VitreoRetinal Consultant
Sana’a University
2022

3. History of Pediatric Keratoplasty

4. • 1824 Reisinger – First animal graft and coined the term “keratoplasty”
• 1831 Dieffenbach proposes partial-thickness keratoplasty (LKP, extraocular procedure)
• 1846 First use of general anesthesia – ether, at the Massachusetts General Hospital,
Boston, MA
• 1878 Arthur von Hippel, invented circular cutting trephine, blades of different diameters,
a key for winding up the watch mechanism
• 1888 Arthur von Hippel, first successful LKP in man
• 1908 Plange – First human lamellar autograft (clear cornea from blind eye to opposite,
scarred eye of the same patient). Graft remained clear for 5 years.
• 1912 Magitot – Use of human cornea previously preserved in an antiseptic fluid for
corneal transplantation.

5. • Real progress in past 40 years- KPro design, material, prevention and
management of complications
• Widespread use limited by early and late complications
• The Dohlman or Boston Keratoprosthesis is the most popular now
• in 1955 Tudor Thomas ,conceived the idea of a donor system for corneal grafts and
an eye bank was established in East Grinstead .
• In 1905 The first cornea transplant was performed by Eduard Zirm .

6. Terminologies of Pediatric keratoplasty

7. Keratoprosthesis
keratoplasty
Corneal Transplantation
Corneal Grafting

8. Definitions of Pediatric keratoplasty

9. The cornea: is the transparent front part of the eye that covers
the iris, pupil and anterior chamber.

10. Keratoplasty simply means surgery to the cornea.

11.  Keratoplasty is a surgical procedure where a damaged or diseased cornea is
replaced by donated corneal tissue (the graft).
 When the entire cornea is replaced it is known as Penetrating Keratoplasty and
when only part of the cornea is replaced it is known as lamellar keratoplasty.

12. Keratoprosthesis: is a surgical procedure where a severely damaged or diseased cornea
is replaced with an artificial cornea to restore useful vision or to make the eye
comfortable in painful keratopathy

13.  The graft is taken from a recently deceased individual with no
known diseases or other factors that may affect the chance of
survival of the donated tissue or the health of the recipient.
 Donors can be of any age, as is shown in the case of Janis Babson,
who donated her eyes after dying at the age of 10.
 Corneal transplantation is performed when medicines,
keratoconus conservative surgery and cross-linking can no longer
heal the cornea.
 This surgical procedure usually treats corneal blindness,[with
success rates of at least 41% as of 2021.

14. Indications of Pediatric keratoplasty

15. Congenital CO:
CHED
Congenital CO:
Non-CHED
Acquired
Traumatic
Acquired
Non-
Traumatic

16. 1- With Associated Glaucoma
a. Congenital glaucoma
b. Peters’s anomaly
c. Other anterior segment dysgenesis
2. Without glaucoma
a. Sclerocornea
b. Dermoid
c. Birth trauma
d. Metabolic disease
e. Keloid
f. Aniridia
Acquired non-Traumatic
a. Keratoconus
b. Infective keratitis with or without
perforation
c. Post infective corneal/ Corneo-iridic
Scars
d. Keratomalacia
Anterior segment photographs of eyes where congenital corneal opacity spontaneously regressed. a, b The right eye of a female patient with Peters anomaly at 25 days (a) and 15
months of age (b). c, d The left eye of a male patient with Peters anomaly at 22 days (c) and 6 months of age (d). e, f The left eye of a male patient with Peters anomaly

17. Types of Pediatric keratoplasty

18. Types:
A. Based on Location
1. Central
2. Peripheral—Circular, oval, crescentic, annular,
semilunar, rectangular or strip graft
3. Total—central and peripheral
4. Corneoscleral
B. Based on Stem-cell Transplantation
1. Non-stem cell KP
2. KP with stem cell transplantation (SCT)

19. Types of keratoplasty
Based on the thickness of the cornea transplanted, keratoplasty
can be divided as:
• Penetrating keratoplasty- involved full thickness of the
cornea.
• Lamellar keratoplasty- involves a transplantation of a part.
 Anterior lamellar : SALK, MALK, DALK, TALK
 Posterior lamellar : DLEK, DMEK, DSAEK

20. Contraindications of Pediatric keratoplasty

21.  Dry Eye
 Blepharitis
 Ectropion
 Entropion
 Recurrent ocular infection
 Melting cornea
 Herpetic infection
 Uveitis
 Uncontrolled Glaucoma

22. Challenges of Pediatric keratoplasty

23.  Sever Ocular pathology
 Technically difficult
 Smaller eye
 Elastic sclera
 Shallow AC
 Anterior displacement iris/ Lens
 Young age
 Poor cooperation
 Hard to examine
 Sudden rapid rejection
The patients are different
The Eyes are different
The disease are different
The surgery and anesthesia are different

24. Complications of Pediatric Penetrating
keratoplasty

25.  Allograft rejection
 Corneal scarring and neovascularization
 Iridocorneal adhesions
 Glaucoma
 Cataract
 Wound dehiscence
 Amblyopia
 Corneal steepening and high astigmatism
 Graft infection and ulcer
 Endophthalmitis
 Persistent epithelial defect
 RD
 Phthisis

26. Alternatives to Pediatric keratoplasty

27. • Contact lenses
• Phototherapeutic keratectomy
• Intrastromal corneal ring segments
• Corneal collagen cross-linking

28. Pre operative Evaluation
  Electroretinography (ERG) and Visually Evoked Response (VER) helpful in
predicting the visual potential.
  Pre operative Ultrasound examination to rule out presence of Retinal
Detachment and other posterior segment abnormalities.
  IOP should be maximally controlled before surgery

29. Surgical Procedure Keratoplasty

30. Animations Videos for Keratoplasty

34. Postoperative Care of Pediatric
keratoplasty

35.  First 2 months
 2-3x / week
 Frequent Postopretive EUAs
 Early suture removal
 Long term – slow taper of topical steroid
over one year
 Sedation p.r.n
 No vaccination for one year
 Co-management with pediatric
ophthalmologist necessary
 Optical correctio ASAP after suture removal

36. Prognosis
 Best:
 • Multiple Graft failure in a relatively non-inflamed eye with intact tear and blink
mechanisms (following dystrophies, infections, etc)
 • Aniridia and other limbal stem cell failure cases Intermediate:
 • Chemical burns, HSV
 Worst:
 • Autoimmune diseases
 • Mucous membrane pemphigoid
 • Stevens-Johnson syndrome
 Chronic uveitis