Severe Autoimmune Keratitis Requiring Tectonic Keratoplasty

Abstract

Abstract: : Purpose: To examine the outcome of patients with severe autoimmune keratitis who required tectonic keratoplasty. Methods: We studied 18 eyes (16 patients) with autoimmune keratitis treated with emergency tectonic lamellar or penetrating keratoplasty. The parameters evaluated include indications for surgery, type of graft (lamellar or penetrating), complications if any, postoperative outcome, and visual acuity. Results: Surgical indications included perforation (15 eyes; 83%) or impending perforation (3 eyes; 17%). The initial procedure was either a penetrating keratoplasty (13 eyes; 72%) or lamellar keratoplasty (5 eyes; 28%). Recurrent melting with a particularly aggressive course requiring multiple repeat grafts occurred with active rheumatoid arthritis (4 eyes in 3 patients), and Mooren's ulcer (4 eyes in 3 patients). The most common postoperative complication was recurrent melting in the graft (13 eyes; 72%), followed by infectious keratitis (5 eyes; 28%). Endophthalmitis did not occur in our patients. The disease progression required additional surgical intervention in 10 eyes (56%). One patient with rheumatoid arthritis required over 30 keratoplasty procedures divided between both eyes over several years for recurrent, bilateral melting with perforation. In our series structural integrity was re-established in every case. Postoperative visual acuity >20/200 was found in 10/18 (56%) of eyes. Notably, 7 of 8 eyes (87.5%) with progressive corneal melting showed a cessation of the melting when placed on systemic Cyclosporine A, despite prior use of other immunosuppressive agents. Conclusions: Our series demonstrates that tectonic keratoplasty can help re-establish structural integrity for autoimmune melting. In our series, recurrent melting was the most common postoperative complication encountered. Cases of active rheumatoid arthritis and severe cases of Mooren's ulcer were associated with severe recurrent corneal melts requiring multiple tectonic keratoplasties. Systemic Cyclosporine A can be a valuable adjunct in the treatment of particularly severe, progressive corneal melting.

Keywords: cornea: clinical science • keratitis • transplantation