Summary for the Clinician

•Compliance with postoperative care including the proper administration of eye drops is crucial for graft survival.

•Regular postoperative follow-up including EUAs are required as infants are unable to communicate their symptoms.

•Sutures can be removed significantly earlier in infants due to their faster wound healing.

•Optical correction and amblyopia therapy should be initiated early to optimize visual outcomes.

Postoperative Complications

Glaucoma

Glaucoma is a frequent complicating factor in infants who have had penetrating keratoplasty surgery. The etiological mechanisms are diverse and include steroid-induced glaucoma, associated anterior segment dysgenesis, persistent anterior chamber inflammation, peripheral anterior synechiae, and surgically induced trabecular meshwork collapse http://www.expertconsultbook.com/expertconsult/b/ linkTo?type=bookPage&isbn=978-0-323-06387-6&eid=4-u1.0-B978-0-323-06387- 6..00132-X--bib76&appID=NGE [29, 35]. Glaucoma is associated with reduced allograft survival as well as causing irreversible optic nerve damage [3, 13, 16, 43, 45, 53].

Initial management includes topical glaucoma medications such as beta-adrener- gic antagonists, carbonic anhydrase inhibitors, and prostaglandin analogs [29, 34]. Selective a-adrenergic agonists should be avoided as they may cause central nervous system depression in infants and young children [9]. It is important to regularly monitor infants for side effects from topical glaucoma medications. In patients where medical therapy does not adequately control IOP or is not tolerated, surgical intervention may be required. Surgical options include goniotomy, trabeculectomy with or without an anti-fibrotic agent, glaucoma drainage tube insertion, and cyclodestructive procedures [7, 25]. Occasionally, concurrent management of glaucoma and corneal opacification is required. The optimal timing and sequence of penetrating keratoplasty and glaucoma filtration procedures (trabeculectomy or tube) is still unclear [3, 4, 29]. Whenever possible, it is best to control the IOP prior to performing the corneal transplant as uncontrolled IOP may deleteriously affect the graft.

Graft Rejection

Immune rejection should be suspected in a cloudy allograft that was previously clear, particularly if associated with anterior chamber inflammation [45]. The classic signs of keratic precipitates or a Khoudadoust (rejection) line is less commonly

seen in the pediatric age group [29, 44]. Most commonly, the patients present with diffuse epithelial edema of the corneal graft. Initial treatment consists of intensive topical corticosteroids such as dexamethasone 0.1% or prednisolone acetate 1% hourly that is titrated to treatment response. Topical cyclosporine may also have a role in the prevention of immune graft rejection in pediatric keratoplasty [14]. In recalcitrant cases, oral corticosteroids may be needed at a dosage of approximately 1 mg/kg/day.

Graft Failure

Allograft failure occurs most commonly within the first postoperative year and infants should be closely monitored during this period [3, 45]. The risk factors for graft failure are shown in Table 7.1. Repeat penetrating keratoplasty in infants is associated with a higher graft failure rate [16, 45]. In patients with possible immune rejection, a course of intensive topical steroids should be given. A regraft may be considered if the cornea fails to clear and the eye has been quiescent for at least 3 months.

Summary for the Clinician

•Glaucoma frequently complicates infant keratoplasty and should be managed appropriately as it is associated with increased risk of graft failure.

•Immune rejection and allograft failure are important postoperative complications of infant keratoplasty.