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Joshua H. Hou, Jose De la Cruz, Ali R. Djalilian; Predictors of Keratoplasty Failure after Keratolimbal Allograft Transplantation and Long-term Outcomes of Boston Keratoprosthesis Implantation as Subsequent Salvage Therapy in Ocular Surface Disease. Invest. Ophthalmol. Vis. Sci. 2011;52(14):331.
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To evaluate: 1) factors in patients with ocular-surface disease that may contribute to higher rates of PKP corneal-graft failure following keratolimbal allograft (KLAL) and may indicate need for alternative therapy with keratoprosthesis (Kpro); and 2) outcomes of Kpro as salvage therapy in patients with failed PKP grafts after KLAL.
Retrospective, non-comparative interventional case series of 8 eyes in 7 consecutive patients with ocular-surface disease and limbal stem cell deficiency (LSCD) treated with Boston Kpro type I for penetrating keratoplasty (PKP) graft failure after KLAL. The underlying diagnoses included aniridic keratopathy (4 eyes), chemical burn injury (2 eyes), atopic keratoconjunctivitis (1 eye), and Steven-Johnson Syndrome (1 eye). Risk factors for graft failure, time to corneal graft failure, number of prior all-cause graft failures, as well as Kpro device retention rate, and preoperative and postoperative BCVA were studied.
In the studied cohort, PKP graft failure occurred at an average of 9.9 months (range, 1-17) after KLAL. The average number of prior all-cause graft failures was 1.6 in studied eyes. Among the 8 eyes reviewed, 4 had tube shunts, 3 of which were considered the primary reason for the endothelial cell failure. One eye failed due to fungal keratitis in the graft PKP. Immune mediated endothelial rejection was the cause of PKP graft failure in the remaining eyes. Except for two eyes which had associated KLAL failure and recurrent surface disease, all other 6 eyes had a stable ocular surface at the time of PKP failure. During an average follow-up of 577 days (19 months) after Kpro, BCVA improved from a median CF@1ft (range, HM-20/400) to a median 20/300 (range, CF@1ft-20/25). There was 87.5% (7/8) retention of implanted devices at last follow-up, with one eye requiring repeat Kpro for corneal melt and implant extrusion despite immunosuppression.
Despite successful KLAL outcome and systemic immunosuppression, patients are still at risk for subsequent PKP graft failure. Previous corneal-graft failure of any type (whether due to poor compliance or difficult to control immune-response) and risk factors for endothelial decompensation (such as tubes) may predict poor long-term outcomes with PKP after KLAL. Keratoprosthesis is a viable salvage therapy for visual rehabilitation of failed PKP after KLAL and should potentially be considered earlier as an alternative in these select patients.
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