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CASE REPORT DEEP ANTERIOR LAMELLAR KERATOPLASTY IN A 15 DAY OLD INFANT

CASE REPORT DEEP ANTERIOR LAMELLAR KERATOPLASTY IN A 15 DAY OLD INFANT. DR ABHAY SUBRAMANIAM DR BHASKAR SRINIVASAN SANKARA NETHRALAYA FP627. INTRODUCTION.

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CASE REPORT DEEP ANTERIOR LAMELLAR KERATOPLASTY IN A 15 DAY OLD INFANT

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  1. CASE REPORTDEEP ANTERIOR LAMELLAR KERATOPLASTY IN A 15 DAY OLD INFANT DR ABHAY SUBRAMANIAM DR BHASKAR SRINIVASAN SANKARA NETHRALAYA FP627

  2. INTRODUCTION • Infectious keratitis, Congenital Glaucoma, Corneal Trauma, Dystrophies are the common indications to perform penetrating keratoplasty in children5 • Surgery is performed in children early to prevent amblyopia • Graft rejection and Secondary glaucoma are the most common causes of failure in the post operative period.5

  3. PRESENTING COMPLAINTS • 15 day old infant • Complaints of discharge, redness and white spot in left eye since 1 day. • Birth history: normal delivery • No discharge in eyes after delivery • No history of instillation of any oil or drops or medications in eyes

  4. On examination: • Right eye – normal • Left eye • Lid edema • Conjunctiva • Circumcorneal congestion • Discharge • Cornea • Cornea --ring abscess • Partly involving visual axis • Thinning with desmatocele • Fundus • No view • USG Normal

  5. Due to severity of infection and the thinning of cornea • Therapeutic keratoplasty advised • Surgery • DALK under GA • Microbiology of cornea button • Gram negative bacilli • Pseudomonas aeruginosa

  6. POST OPERATIVE TREATMENT • ANTIBIOTIC EYE DROPS • Fortified cephazolin eye drops • Moxifloxacin eye drops • Ciprofloxacin eye ointment • TOPICAL STEROIDS • Prednisolone acetate eye drops

  7. 2 MONTHS POST OP • Graft clear • Interface normal • Both eyes patient was fixing and following light • Patient was resisting occlusion in right eye • Advised patching in right eye for 1 hour • All sutures removed • POST DILATED RETINOSCOPY Right Eye:+4.00DS/-1.25DC@180° Left Eye:+4.50DS/-1.50DC@170°

  8. 4 MONTHS POST OP • Both eyes equally resists occlusion • Both eyes central/steady/maintained • POST DILATED RETINOSCOPY Right Eye:+3.75DS/-2.00DC@10° Left Eye:+4.00DS/-1.50DC@170°

  9. DISCUSSION • The options available to us for the corneal thinning and severe infection were cyanoacrylate glue v/s DALK • Glue prevents deep penetration of topical medications thus prolonging recovery. • LK has been performed in patients with infective keratitis unresponsive to treatment1,2 • In order to debulk the infection, prevent corneal perforation and the need to provide early visual rehabilitation due to the paracentral corneal involvement a DALK was undertaken in this case

  10. DISCUSSION • Advantages of LK include maintenance of globe integrity, a significant reduction in quantity and duration of postoperative steroid therapy, nearly complete absence of graft rejection, a low rate of acute and chronic endothelial cell loss6 , total removal of infected stroma while maintaining an intact descemet membrane as a barrier.1 • Success of PK in infants and children is limited especially in cases of active infection .Low scleral rigidity, increased intraoperative fibrin formation, and positive vitreous pressure complicate the surgical procedure. 3

  11. DISCUSSION • Corneal graft failure in PK is most frequently the result of the destruction of the donor endothelium4 .LK has the advantage of avoiding endothelial decompensation with better graft survival especially in the setting of infective keratitis and a pediatric age group both of which are high risk situations for conventional full thickness keratoplasty • PUBMED SEARCH REVEALS NO REPORT OF DALK BEING PERFORMED IN A 15 DAY OLD INFANT FOR INFECTIOUS KERATITIS. • DALK CAN BE CONSIDERED AS A TREATMENT OPTION FOR YOUNG INFANTS AND CHILDREN WITH INFECTIOUS KERATITIS.

  12. REFERENCES • ANAND PARTHASARATHY ET AL:DEEP LAMELLAR KERATOPLASTY FOR ACANTHAMOEBA KERATITIS CORNEA 2007;26:1021–1023 • LIXIN XIE ET AL:LAMELLAR KERATOPLASTY FOR THE TREATMENT OF FUNGAL KERATITIS CORNEA 21(1): 33–37, 2002. • MURALI K. AASURI ET AL: PENETRATING KERATOPLASTY IN CHILDREN CORNEA 19(2): 140–144, 2000. • BRUCE A. NOBLE ET AL DEEP ANTERIOR LAMELLAR KERATOPLASTY (DALK) VISUAL OUTCOME AND COMPLICATIONS FOR A HETEROGENEOUS GROUP OF CORNEAL PATHOLOGIES CORNEA 2007;26:59–64 • NAMRATA SHARMA, MD ET AL: PEDIATRIC KERATOPLASTY IN INDIA: INDICATIONS AND OUTCOMES CORNEA 2007;26:810–813 • VINCENZO SARNICOLA, MD ET AL:DEEP ANTERIOR LAMELLAR KERATOPLASTY IN HERPES SIMPLEX CORNEAL OPACITIES CORNEA 2010;29:60–64

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