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Systemic ciclosporin A in high-risk keratoplasties
T Reinhard1, R Sundmacher, P Heering
1Department of Ophthalmology, Heinrich Heine University, Düsseldorf, Germany.
Insights
Systemic ciclosporin A (Ci A) effectively suppresses immune reactions in high-risk keratoplasty. However, resurfacing disorders become the primary cause of graft failure, necessitating limbal stem cell transplantation alongside Ci A for better outcomes.
Area of Science:
- Ophthalmology
- Transplantation Immunology
- Corneal Surgery
Background:
- High-risk keratoplasty (kp) presents significant challenges due to potential immune reactions and graft failure.
- Systemic immunosuppression with ciclosporin A (Ci A) has been explored to mitigate these risks.
- This study retrospectively analyzes kp outcomes under Ci A cover.
Purpose of the Study:
- To evaluate the efficacy of systemic ciclosporin A (Ci A) in high-risk keratoplasty (kp).
- To identify the primary causes of graft failure in patients receiving Ci A.
- To determine optimal strategies for improving long-term graft survival in challenging cases.
Main Methods:
- A retrospective analysis of 131 high-risk keratoplasties (kp) performed between 1987 and 1994.
- Patients received systemic ciclosporin A (Ci A) for an average of 9.4 months, targeting trough levels of 100-150 ng/ml.
- Patients were categorized into four groups (A-D) based on pre-existing conditions, including repeat grafts, severe vascularization, ocular surface disorders, and limbal stem cell insufficiency.
Main Results:
- Graft clarity rates at 2 years varied significantly by group: 91% (Group A), 76% (Group B), 38% (Group C), and 18% (Group D).
- Resurfacing problems were identified as the primary or contributing factor in 78% of graft failures.
- Immune reactions were a less significant cause of graft failure compared to resurfacing issues.
Conclusions:
- Systemic ciclosporin A (Ci A) effectively controls immune reactions in high-risk keratoplasty.
- Following immune suppression, ocular surface and limbal stem cell-related resurfacing disorders emerge as the main cause of graft failure.
- Combining limbal stem cell transplantation with systemic Ci A is recommended to enhance long-term prognosis for penetrating keratoplasty in eyes with stem cell deficiency.
Background:
It was the purpose of this study to compile the results of all high-risk keratoplasties (kp) performed in our hospital under systemic ciclosporin A (Ci A) cover from 1987 through 1994.
Methods:
One hundred and thirty-one keratoplasties were performed. Ci A was administered for an average period of 9.4 months. We aimed at trough levels of 100-150 ng/ml (monoclonal RIA/TDx). The 29 kp in group A were second or third repeat kp and/or the recipient cornea had severe deep vascularization in all quadrants and/or a transplant position at the limbus was inevitable (expected risk: only immune reactions). The 40 kp in group B were threatened by severe ocular surface disorders (without severe limbal stem cell insufficiency) and by immune reactions (atopic keratopathy, keratoconus with severe endogenous eczema or chronic blepharokeratoconjunctivitis). In the 45 kp of group C resurfacing problems from severe limbal stem cell insufficiency and immune reactions were anticipated (severe burns, pseudopemphigoid or Lyell syndrome). Group D comprised 17 kp with various diagnoses (e.g. kp in newborns, rheumatic and Acanthamoeba keratitis).
Results:
In group A 91% of the grafts were clear 2 years postoperatively, in group B 76%, in group C 38% and in group D 18%. In 32 of 41 failed grafts (78%), resurfacing problems were the only reason for or participated in final graft failure. Immune reactions and other causes of graft failure were of minor importance.
Conclusions:
(1) Systemic Ci A cover can efficiently suppress immune reactions. (2) With the suppression of immune reactions, resurfacing disorders become the most important single cause for functional graft failure. (3) For eyes with a considerable loss of limbal stem cells, limbal stem cell transplantation should be combined with systemic Ci A cover in order to improve the long-term prognosis for penetrating keratoplasty.