Late Stromal Rejection in Deep Anterior Lamellar Keratoplasty: A Case Series

To report a series of 4 cases (3 patients) with late stromal graft rejection 32 to 46 months after an uneventful deep anterior lamellar keratoplasty (DALK).

Three patients (4 eyes), who had undergone an uneventful DALK for keratoconus (3 eyes) and infectious keratitis (1 eye) 32 to 46 months previously presented with a history of ocular discomfort and redness, with reduced visual acuity in 3 eyes. In all cases, all sutures had been removed at least 18 months previously. On examination, there was superficial and in 2 eyes deep neovascularization. In 2 eyes, the vessels extended within the interface between the donor and host corneas. The stroma of the donor cornea adjacent to the areas of vascularization was edematous. A diagnosis of stromal graft rejection was made, and the patients were administered intensive topical corticosteroids.

All eyes responded well to treatment, becoming more comfortable, with decreasing redness, reversal of corneal edema, and return of prerejection best corrected visual acuity with up to 18 months follow-up. The patients continued to receive tapering dosage of topical corticosteroid for 12 months. In 1 eye topical steroids were reintroduced at 13 months because of a further rejection episode.

These cases of late stromal rejection after DALK provide clinical evidence that donor keratocytes may persist in such lamellar grafts for extended periods and that patients should be warned that rejection may occur years after surgery.