[Keratoplasty in children--still a dilemma]

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.

Potential indications for surgery are classified as follows: (i) congenital cloudiness (e.g., congenital hereditary endothelial dystrophy--CHED), (ii) acquired traumatic scars, (iii) acquired non-traumatic scars (e.g., infections, keratoconus) and (iv) irreversible graft failure. Our experience concerning 126 paediatric PKPs between 1980 and 2002 in children under age 16 is reported. Five case reports of PKPs performed in Homburg/Saar from 2006 are added.

To minimise 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 should be avoided in view of the histopathology, in cases of Peters' anomaly an optical sector iridectomy may be considered as a valid alternative to high-risk PKP. In cases of buphthalmos the IOP must be controlled before PKP (e.g., previous trabeculotomy). In cases 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 interrupted sutures in children. In addition, early suture removal is attempted, especially in cases of progressive corneal neovascularisation threatening the graft. If in doubt, examinations are performed in general anaesthesia readily.

Corneal grafting in children should be performed as soon as necessary (less amblyopia!), but as late as possible (better cooperation!). In children, critical indication, repeated in-depth counselling of the parents, good cooperation with the anaesthetist and excellent cooperation with the paediatric ophthalmologist are indispensable in order to achieve good morphological and functional results after PKP.