Corneal transplantation in children - when and how?

ABSTRACT

Introduction

Advanced surgical techniques, better post-operative protocols, imaging, and better understanding of genetic basis have enhanced outcomes of pediatric keratoplasty. However, results in infants and younger children remain a challenge. Transplants in the pediatric age group are challenging because of the complexity of the indications, the procedure itself, and the problems with respect to follow-up and post-operative care in younger recipients.

Areas covered

This review presents an overview of challenges faced in the management of pediatric corneal grafts, and problems encountered in long-term survival. We discuss the changing trends in these outcomes of PKP with a current review of the recent literature from PubMed. We also share the results of pediatric keratoplasty done at our center in the last three years and have an in-depth discussion about the management of comorbidities like cataracts and glaucoma

Expert opinion

Despite several advances in microsurgical techniques for corneal transplantation, pediatric keratoplasty remains challenging due to a variety of factors such as young age, repeated need for anesthesia, immature ocular tissues, and accelerated healing. The advent of component surgeries like DALK, DSEK, and DMEK has improved outcomes and simplified management options. Even after specialized surgeries, long-term follow-ups and management of comorbidities become essential.

KEYWORDS:

• Penetrating keratoplasty
• congenital corneal opacity
• anterior segment dysgenesis
• congenital glaucoma
• endothelial rejection
• peters anomaly
• limbal stem cell deficiency

Article highlights

• Common indications for keratoplasty globally in infants and younger children are congenital abnormalities and acquired non-traumatic causes.

• Full-thickness penetrating keratoplasty is usually performed in these cases. Modifications to improve the outcomes and avoid complications are in practice.

• Outcomes of pediatric keratoplasty are case-specific and are dependent on regular follow-ups and management of comorbidities like cataract, glaucoma, and amblyopia to enhance the long-term outcomes.

• Newer techniques include simple limbal epithelial transplant, selective endothelialectomy and femto-assisted lamellar keratoplasty. Bioengineered and liquid cornea is also under research.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Ethics

The authors state that institutional review board approval was obtained from Dr Shroff’s Charity Eye Hospital, New Delhi, to review and publish the analysis of patient records for pediatric keratoplasty. Consent to publish patient photos was obtained from the parent/guardian(s) of the child.

Abbreviations

AC: Anterior Chamber ONH: Optic nerve head KILD: Kerato-irido-lenticular Dysgenesis: CHED: Congenital Hereditary Endothelial Dystrophy IOP: Intraocular Pressure UBM: Ultrasound biomicroscopy PPMD: Posterior polymorphous corneal dystrophy PKP: Penetrating keratoplasty TPK: Therapeutic keratoplasty OPK: Optical keratoplasty DSEK: Descemet’s stripping endothelial keratoplasty DSAEK: Descemet’s stripping automated endothelial keratoplasty PCG: Primary congenital glaucoma DMEK: Descemet’s membrane endothelial keratoplasty DALK: Deep anterior lamellar keratoplasty FALK: Femto-assisted keratoplasty ALTK: Anterior lamellar keratoplasty AAK: aniridia associated keratopathy: LSCD Limbal stem cell deficiency EUA: examination under anesthesia IOP: intraocular pressure CAI: carbonic anhydrase inhibitor SLET: Simple limbal epithelial transplant OCT: Optical coherence tomography AS-OCT: Anterior segment-Optical coherence tomography IOL: intraocular lens MMC: mitomycin C AGM: Antiglaucoma medications TSCPC: Transscleral cyclophotocoagulation VKC: Vernal keratoconjunctivitis AGV: Ahmed glaucoma valve

Additional information

Funding

This paper was not funded.