easily without risking wound dehiscence, as is the case with a running suture technique. Subconjunctival antibiotics and steroids are administered and a firm pad and shield should be placed at the conclusion of surgery.

Concurrent Surgical Procedures

Concurrent procedures such as vitrectomy, synechiolysis, and lensectomy are known to be associated with poorer graft survival [1, 13, 24, 29, 45]. They may be planned or unplanned secondary to a surgical complication. When performing lensectomy concurrently with penetrating keratoplasty, it is often necessary to perform a posterior capsulotomy, anterior vitrectomy, and peripheral iridectomy. All vitreous in the anterior chamber should be removed with care to prevent vitreous adhering to the wound and iris. If possible, it has been the practice at our center to stage the cataract removal. In other words, if a cataract is present, or there is firm corneo-lenticular adhesion, the lens is removed whilst preserving the posterior capsule. Then at a later date, 2–4 weeks after the transplantation, a pars plicata, closed capsulectomy can be performed. We believe this approach is safer for the patient and allows for a more thorough removal of the vitreous in a closed ocular setting.

Summary for the Clinician

•Penetrating keratoplasty in infants is more difficult secondary to decreased scleral rigidity and increased posterior vitreous pressure and modifications to surgical technique are required.

•Interrupted 10-0 nylon sutures are recommended to reduce the risk of wound dehiscence.

•Concurrent procedures, whether planned or unplanned, are associated with reduced graft survival.

Postoperative Considerations

Postoperative care in infants is different to adults and is often challenging. A protective shield is essential and in some circumstances, arm restraints or splints may be necessary. However, young infants rarely generate much force, so self-injury is uncommon. Initially, topical antibiotics, corticosteroids, and cycloplegics are started and parents must understand the importance of compliance with medications. Corticosteroids are used at a higher dose and tapered more slowly than in adults as the inflammatory response is markedly greater in the pediatric age group. Cosar et al. [14] described the addition of topical cyclosporine 2% to topical corticosteroids in pediatric keratoplasty and found a reduced immune rejection rate

compared with using corticosteroids alone. Family members should be instructed not to force the eye open when instilling drops as excessive force may result in inadvertent wound rupture. An alternative is for drops to be instilled in the nasal corner of the eye, and as the child blinks, the medication will reach the anterior segment.

Infants can usually be examined with a portable slit lamp whilst sitting on the parents’ lap or whilst feeding. Otherwise they may be wrapped with a blanket and restrained, with or without the use of a lid speculum. Nonetheless, it is best to try and sneak up on a calm infant. One needs to only inspect for graft clarity, integrity of the wound, loose sutures, and presence of an anterior chamber. If there is poor cooperation, an EUA may need to be performed. Regular follow-up examinations are required as infants are unable to communicate their symptoms.

In the initial postoperative period, it is important to ensure that the wound is watertight, the anterior chamber is formed, and the IOP is within normal range. In the first 1–2 weeks, the infant is monitored closely until the ocular surface is fully epithelialized as a persistent epithelial defect is a risk factor for microbial keratitis [50].

Suture Management

In infants, sutures may be removed as early as 4 weeks due to their faster wound healing [24, 29]. The infant needs to be monitored at least weekly until all sutures are removed. Suture removal is incrementally delayed with increasing age of the child and must be balanced against the risk of graft dehiscence. Any loose, eroded, or broken sutures should be removed promptly to avoid suture-related infection and neovascularization. The precise timing in ceasing topical antibiotics varies by practice but may be discontinued a month or so after all sutures have been removed [50].

Optical Correction and Amblyopia Therapy

Amblyopia is a unique and important consideration following penetrating keratoplasty in infants and young children [21, 29]. It is a major factor limiting postoperative visual outcome despite surgical success. Joint management with a pediatric ophthalmologist is helpful for early refractive correction and aggressive amblyopia therapy [24]. Regular cycloplegic refractions are required following surgery and performed as soon as possible after surgery. Although contact lenses are associated with an increased risk of corneal neovascularization and infectious keratitis, they may be very useful if high anisometropia is present [10]. Parents should also be informed that regular prescription changes may be required postoperatively.