Autologous Contralateral and Ipsilateral Rotational Penetrating Keratoplasty – A Case Series and Mini-Review

Abstract

Corneal stromal opacities can severely impact visual acuity if they are located in the visual axis. Homologous penetrating keratoplasty (HPK) is usually the preferred surgical option in such clinical circumstances. However, autologous penetrating keratoplasty (APK) could be an immunologically safer alternative. The purpose of this study was to report the surgical technique, indications, and (dis)advantages of ipsilateral rotational and contralateral APK, as well as pre- and postoperative clinical findings of four patients who underwent contralateral APK. In ipsilateral rotational APK, eccentric trephination places the central corneal opacity at the excision edge, whereafter the corneal button is rotated to clear the visual axis. Contralateral APK is suitable for more specific clinical situations with corneal opacity in a functionally much better eye. Clear cornea of the (almost) blind eye suffering from a noncorneal pathology is transplanted to the potentially better seeing eye suffering from a corneal pathology, followed by HPK in the (almost) blind donor eye. After 18 months, potentially better-seeing eyes improved from logMAR 1.3 to 0.6 in visual acuity, with most HPK-treated weaker eyes matching preoperative levels. Considering ipsilateral rotational and contralateral APK before moving on straight towards HPK is crucial in select cases. Autologous contralateral keratoplasty should be preferred for patients with (1) corneal scars in a potentially better seeing eye and (2) a clear cornea in an (almost) blind eye, especially in cases of high risk for graft rejection.

Zusammenfassung

Stromale Hornhauttrübungen können die Sehschärfe stark beeinträchtigen, wenn sie in der visuellen Achse liegen. Die homologe perforierende Keratoplastik (HPK) ist i. d. R. die bevorzugte chirurgische Option unter solchen klinischen Umständen. Die autologe perforierende Keratoplastik (APK) könnte jedoch eine Alternative ohne das Risiko einer immunologischen Transplantatabstoßung darstellen. Ziel dieser Studie war es, die chirurgische Technik, die Indikationen und die Vor-/Nachteile der ipsilateralen rotatorischen und der kontralateralen APK sowie die prä- und postoperativen klinischen Befunde von 4 Patienten, die sich einer kontralateralen APK unterzogen, darzustellen. Bei der ipsilateralen rotatorischen APK wird eine exzentrische Trepanation durchgeführt, wobei die zentrale Hornhauttrübung am Rand der Exzision liegt. Anschließend wird das Hornhautscheibchen so gedreht, dass sich die klare Hornhaut in der Sehachse befindet, wobei die Narbe zur Peripherie hingedreht wird. Eine kontralaterale APK kann in spezielleren klinischen Situationen mit Hornhauttrübungen im funktionell viel besseren Auge durchgeführt werden. Bei diesem Verfahren wird die klare Hornhaut des (fast) blinden Auges, das an einer nicht kornealen Pathologie leidet, auf das potenziell besser sehende Auge transplantiert, das an einer kornealen Pathologie leidet. Im Rahmen dieses Verfahrens muss am (fast) blinden Spenderauge eine gleichzeitige HPK durchgeführt werden. Die Option der ipsilateralen rotatorischen und der kontralateralen APK sollte in besonderen klinischen Situationen immer zuerst in Betracht gezogen werden, bevor Hornhautmikrochirurgen direkt zur HPK übergehen. Die autologe kontralaterale Keratoplastik sollte bei Patienten mit (1) Hornhautnarben in einem potenziell besser sehenden Auge und (2) klarer Hornhaut in einem (fast) blinden Auge bevorzugt werden, insbesondere in Fällen mit hohem Risiko für eine Transplantatabstoßung.

Conclusion Box

Already known:

• Corneal stromal opacities can cause a severe reduction of visual acuity if located in the visual axis. HPK is usually the preferred surgical option in such clinical circumstances. However, APK could be an alternative, avoiding the risk of an immunological graft reaction due to the autologous origin of the corneal transplant.

• Considering ipsilateral rotational and contralateral APK before moving on straight towards HPK is crucial in select cases.

Newly described:

• Ipsilateral rotational autologous keratoplasty should be considered in patients with a central corneal opacity, in whom the risk of graft failure can be significantly reduced due to the absence of immunological reaction, provided that the patient is willing to accept the disadvantage of a relatively lower postoperative visual acuity without contact lens in exchange for this advantage.

• Contralateral autologous keratoplasty should be preferred for patients with (1) corneal scars in a potentially better seeing eye and (2) a clear cornea in an (almost) blind eye, especially in cases of high risk for graft rejection.

Key words

contralateral autologous keratoplasty - ipsilateral rotational autologous keratoplasty - penetrating keratoplasty - central corneal scar

Schlüsselwörter

kontralaterale autologe Keratoplastik - ipsilaterale rotierende autologe Keratoplastik - perforierende Keratoplastik - zentrale Hornhautnarbe

Publication History

Received: 21 June 2023

Accepted: 12 November 2023

Article published online:
10 October 2024

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