JKOS Journal of the Korean Ophthalmological Society J Korean Ophthalmol Soc 0378-6471 2092-9374 Korean Ophthalmological Society 10.3341/jkos.2013.54.5.704 jkos-54-704 Original Article Clinical Outcomes of Penetrating Keratoplasty in Patients Five Years or Younger YongWoo Kim MD 1 HyukJin Choi MD 1 2 MeeKum Kim MD 1 WonRyang Wee MD 1 YoungSuk Yu MD 1 JooYoun Oh MD 1 Department of Ophthalmology, Seoul National University College of Medicine1, Seoul, Korea Seoul National University Hospital Healthcare System Gangnam Center2, Seoul, Korea Address reprint requests to Joo Youn Oh, MD, PhD Department of Ophthalmology, Seoul National University Hospital #101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea Tel: 82-2-2072-0836, Fax: 82-2-741-3187, E-mail: jooyounoh77@gmail.com 09 2013 7 9 2013 54 5 704 708 28 09 2012 31 10 2012 25 02 2013 Copyright © 2013 Korean Ophthalmological Society 2013 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose

To investigate the clinical outcomes of primary pediatric keratoplasty.

 Methods

Records of patients who underwent penetrating keratoplasty at the age of 5 years or younger were retro-spectively reviewed. The survival rates of corneal grafts, postoperative complications, and causes of graft failure were evaluated.

 Results

A total of 31 penetrating keratoplasties were performed in 29 patients, two of which were bilateral. The mean fol-low-up period was 78.72 ± 8.94 months. The overall graft survival rate was 51.61%. The graft survival rate was 77.4% at 6 months, 61.3% at 12 months, 57.5% at 2 years, and 49.5% at 5 years after the surgery (the median survival time, 39.2 months). The main surgical indications included sclerocornea (35.5%), followed by Peter’s anomaly (25.8%) and congenital glaucoma (9.7%). There were significant differences in graft survival time among the surgical indications, of which scle-rocornea was the worst ( p = 0.003). The main cause of graft failure was rejection (46.7%), followed by infection (26.7%) and primary endothelial decompensation (20%). When patients were sub-grouped according to age (under 12 months, between 12 to 48 months, and over 48 months), there was significant difference in graft survival time ( p = 0.037) but not in overall graft survival rate ( p = 0.154). Graft rejection occurred more frequently in patients between 12 to 48 months of age compared to other age groups ( p = 0.016). Three out of 13 graft infections occurred in patients under 12 months of age.

 Conclusions

The type of disease causing corneal opacity was a significant factor affecting the clinical outcomes of pene-trating keratoplasty in children.

 Graft survival time Penetrating keratoplasty References BermejoEMartinez-FriasMLCongenital eye malformations: clinical-epidemiological analysis of 1,124,654 consecutive births in SpainAm J Med Genet199875497504 GanekalSGangangoudaCDorairajSJhanjiVEarly outcomes of primary pediatric keratoplasty in patients with acquired, atrau-matic corneal pathologyJ AAPOS2011153535 VanathiMPandaAVengayilSPediatric keratoplastySurv Ophthalmol20095424571 Al-GhamdiAAl-RajhiAWagonerMDPrimary pediatric keratoplasty: indications, graft survival, and visual outcomeJ AAPOS200711417 McClellanKLaiTGriggJBillsonFPenetrating keratoplasty in children: visual and graft outcomeBr J Ophthalmol20038712124 StultingRDSumersKDCavanaghHDPenetrating kerato-plasty in childrenOphthalmology198491122230 LoweMTKeaneMCCosterDJWilliamsKAThe outcome of corneal transplantation in infants, children, and adolescentsOphthalmology20111184927 DanaMRSchaumbergDAMoyesALGomesJACorneal trans-plantation in children with Peters anomaly and mesenchymal dysgenesisMulticenter Pediatric Keratoplasty Study. Ophthalmology199710415806 RaoKVFernandesMGangopadhyayNOutcome of pene-trating keratoplasty for Peters anomalyCornea20082774953 YangLLLambertSRDrews-BotschCStultingRDLong-term visual outcome of penetrating keratoplasty in infants and children with Peters anomalyJ AAPOS20091317580 YangLLLambertSRLynnMJStultingRDLong-term results of corneal graft survival in infants and children with peters anomalyOphthalmology199910683348 HuangCO'HaraMMannisMJPrimary pediatric keratoplasty: indications and outcomesCornea20092810038 Figures and Tables

The Kaplan-Meier survival curve of corneal grafts. The overall graft survival rate was 51.6%. The graft survival was 77.4% at 6 months, 61.3% at 12 months, 57.5% at 2 years and 49.5% at 5 years after the surgery.

The Kaplan-Meier survival curve of corneal grafts according to the surgical indications. Corneal mass, CHED and Peter’s anomaly show favorable outcome whereas scle-rocornea, congenital glaucoma, acquired corneal opacities and aniridia showed poor outcome. The differences of median sur-vival time among the surgical indications reached statistical significance ( p = 0.003, Log-Rank test).

The Kaplan-Meier survival curve of corneal grafts according to the age groups. The mean survival time of cor-neal grafts according to the age groups was significantly dif-ferent; 72.26 ± 17.62 months in age under 12 months vs 54.03 ± 20.57 months in age 12 to 48 months vs 144.03 ±14.60 months in age over 48 months ( p = 0.037, Log-Rank test).

The Kaplan-Meier survival curve of corneal grafts according to the use of topical intraocular pressure (IOP) low-ering agents. The median survival time was not significantly different between the patients who used IOP lowering agents due to increased IOP after the surgery and those who did not ( p = 0.810, Log-Rank test).

Patient demographics

Patients (M:F) 29 (15:14)
Age at the time of surgery (months) 24.06 ± 3.72
Diagnosis 100% (n = 31)
Sclerocornea 35.5% (n = 11)
Peter’s anomaly 25.8% (n = 8)
Congenital glaucoma 9.7% (n = 3)
Corneal mass 9.7% (n = 3)
Acquired corneal opacity 9.7% (n = 3)
CHED 6.5% (n = 2)
Aniridia 3.2% (n = 1)
Causes of graft failure
Rejection 46.7%
Infection 26.7%
Primary failure 20.0%
Trauma 6.7%
Acquired corneal opacity: this category in corneal opacity after 1) pars plana vitrectom and 3) traumatic corneal ulcer. CHED = congenital hereditary endothelia ncluded the patients with my, 2) infectious keratitis, al dystrophy.

Complications after the surgery

Complications
Rejection 45.2% (n = 14)
IIOP 32.3% (n = 10)
Cataract 25.8% (n = 8)
Phthisis / Enucleation 22.6% (n = 7)
Infection 16.1% (n = 5)
Causative agents* Achromobacter xylosoxidans
Streptococcus pneumonia
Herpes simplex virus

IIOP = increased intraocular pressure.

Causative agents were unidentifiable in 2 cases.

Survival rates, rejection and infection rates according to age groups

Age <12 months 12-48 months >48 months p-value*
N 13 12 6
Survival 53.85% (7/13) 33.33% (4/12) 83.33% (5/6) 0.154
Rejection 7.69% (1/13) 50% (6/12) 0% 0.016
Infection 23.08% (3/13) 0% 16.67% (1/6) 0.220

Pearson’s chi square test.

The distribution of the final diagnosis according to the age groups

Diagnosis Age N (%) p-value*
<12 months 12-48 months >48 months
Sclerocornea 4 (36%) 7 (64%) 0 (0%) 11 (35.5%)
Peter's anomaly 2 (25%) 4 (50%) 2 (25%) 8 (25.8%)
Acquired cases 2 (67%) 0 (0%) 1 (33%) 3 (9.7%)
Congenital glaucoma 1 (33%) 0 (0%) 2 (67%) 3 (9.7%) 0.091
Corneal mass 3 (100%) 0 (0%) 0 (0%) 3 (9.7%)
CHED 0 (0%) 1 (50%) 1 (50%) 2 (6.5%)
Aniridia 1 (100%) 0 (0%) 0 (0%) 1 (3.2%)

Pearson’s chi square test.