Abstract

SA.09.09

Keratoplasty in children – still a dilemma

Berthold Seitz
Klinik für Augenheilkunde, Universitätskliniken des Saarlandes, Homburg/Saar

Objective
Penetrating keratoplasty (PKP) in children is associated with specific age-related problems. In contrast to adults, children can be examined less easily and they are not readily complaining about symptoms. Thus, the rate of intra- and postoperative complications is higher than in adults. In addition, amblyopia is a major issue before the age of seven years potentially resulting in irreversible reduction of visual acuity.
Methods
Experiences concerning 140 pediatric PKPs between 1980 and 2002 in children under age 16 are reported. Potential indications for surgery are classified as follows: (1) congenital cloudiness (e.g., congenital hereditary endothelial dystrophy CHED), (2) acquired traumatic scars, (3) acquired nontraumatic scars (e.g., infections, keratoconus) and (4) irreversible graft failure.
Results
To minimize the risk of immunological graft rejection and chronic endothelial cell loss, we prefer PTK, lamellar keratoplasty or ipsilateral autologous rotational keratoplasty whenever possible. In cases of sclerocornea we feel that PKP is contraindicated in view of the histopathology, in case of Peters‘ anomaly an optical sector iridectomy may be considered as a valid alternative to high-risk PKP. In case of buphthalmos the IOP must be controlled before PKP (e.g. previous trabeculotomy). In case of central penetrating cornea and lens injuries we advocate simultaneous PKP and IOL implantation in the quiet interval after primary wound closure to achieve quick optical rehabilitation. We prefer smaller grafts and single sutures in children. In addition, early suture removal is attempted, especially in case of progressive corneal neovascularization threatening the graft. If in doubt, examinations are performed in general anesthesia readily.
Conclusions
Corneal grafting in children should be performed as soon as necessary (less amblyopia!), but as late as possible (better cooperation!). To achieve good morphological and functional results after PKP in children, critical indication, repeated in-depth counseling of the parents, good cooperation with the anaesthesist and excellent cooperation with the pediatric ophthalmologist are indispensable.

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