Management of Post-Keratoplasty Astigmatism
Management of Post-Keratoplasty Astigmatism
Management of Post-Keratoplasty Astigmatism
Post-keratoplasty astigmatism remains a challenge for corneorefractive surgeons. While maintaining a healthy graft is the most crucial issue in keratoplasty procedures, astigmatism is a limiting factor in the visual rehabilitation of otherwise successful corneal grafts. The management of post-keratoplasty astigmatism takes place at 2 stages: when sutures are still present at the grafthost junction and when all sutures have been removed. Excessive suture-in post-keratoplasty astigmatism is usually managed by selective suture manipulation, ie, suture adjustment and/or suture removal along the steep meridian of astigmatism. A small amount of suture-out post-keratoplasty astigmatism can be managed by spectacles. Higher magnitudes of astigmatism can be addressed by contact lenses or surgical intervention, such as relaxing and compressing procedures. Laser lamellar refractive surgery can also be used to manage post-keratoplasty astigmatism, and toric phakic intraocular lenses have recently been recommended. In this review, we discuss the etiology and management of post-keratoplasty astigmatism and provide recommendations and tips to minimize it. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2012; 38:20292039 Q 2012 ASCRS and ESCRS
Keratoplasty, also known as corneal transplantation, is a surgical procedure in which a damaged or diseased cornea is replaced entirely (penetrating keratoplasty) or partially (lamellar keratoplasty) by a donated corneal graft. The history of corneal transplantation extends from the ancient Egyptians to the first reported successful corneal transplantation by Eduard Zirm in 1905.1 Many individuals have contributed to the development of keratoplasty by proposing new techniques and introducing improvements in surgical instruments and suture materials that refined keratoplasty procedures. Today, keratoplasty comprises 3 basic types:2 (1) penetrating keratoplasty (PKP), in which the entire cornea from epithelium to endothelium is replaced; (2) deep anterior lamellar keratoplasty, in which the recipients endothelium and Descemet membrane, at
times with deep stroma, are preserved and the remainder of the cornea is replaced; (3) endothelial transplantation, in which the recipients Descemet membrane and endothelium, at times with deep stroma, are replaced with corresponding tissue from a donor, such as Descemet-stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK). The goal of keratoplasty is to restore sight that is impaired due to corneal pathology. In the past, success was gauged by the maintenance of a clear cornea over time. Today, while maintaining a clear cornea is important, success is measured by the functional vision attained by the grafted eye. The postoperative refractive error, post-keratoplasty astigmatism particularly, is the single most important factor that contributes to poor visual outcome following otherwise successful keratoplasty.3 ETIOLOGY OF ASTIGMATISM Post-keratoplasty astigmatism is multifactorial in its etiology. The underlying factors can be categorized as preoperative, intraoperative, and postoperative. Preoperative Factors These factors involve the donor tissue and the host.
Donor-Related Factors Age and health of donor tissue
Submitted: August 12, 2011. Final revision submitted: March 2, 2012. Accepted: April 28, 2012. From the Division of Ophthalmology and Visual Sciences, Queens Medical Centre, University of Nottingham, Nottingham, United Kingdom. Corresponding author: Harminder S. Dua, MD, PhD, FRCOphth, Division of Ophthalmology and Visual Sciences, B floor, Eye Ear Nose Throat Centre, University Hospital, Queens Medical Centre, Nottingham, NG7 2UH, United Kingdom. E-mail: harminder.dua@ nottingham.ac.uk.
Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
are occasionally considered to be important factors in post-keratoplasty astigmatism. Infant donor corneas
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.09.002
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are reported to induce greater astigmatism and myopia than adult donor tissues in adult eyes having keratoplasty.46 Butrus et al.7 suggest that nonuniform peripheral changes in the donor tissue such as scarring, thinning, and vascularization may have an effect on apposition and healing of the grafthost junction. Undetected ectatic donor diseases such as keratoconus have been documented to have a significant effect on astigmatism and decreased visual acuity postoperatively.8 The refractive status of the donor tissue, especially corneal dioptric power and astigmatism, is not generally available to surgeons preoperatively. To our knowledge, no studies have evaluated the correlation between post-keratoplasty astigmatism and native donor astigmatism. High quality and healthy donor graft tissues are currently widely available, minimizing the effect of donor-related factors on post-keratoplasty astigmatism.
Recipient-Related Factors Recipient pathology can also contribute to post-keratoplasty astigmatism to a lesser or greater extent. The distribution of preexisting forces in the host cornea may affect astigmatism postoperatively.9 Generally, keratoconic6 and aphakic10 eyes are more likely to have higher degrees of astigmatism. Irregular recipient bed thickness, as in corneal ectasia (keratoconus, keratoglobus, and pellucid marginal degeneration), peripheral melting conditions, and following chronic inflammation, can contribute to graft-host thickness disparity. As the host rim supports the donor graft along its circumference, a thin rim segment will allow the donor button to sag or be displaced, causing astigmatism.11 Similarly, recipient bed vascularization leading to poor or excessive wound-healing response in different sectors can cause warpage of donor tissue and consequent astigmatism.11,12 Intraocular pressure13 and deceased scleral rigidity14 could also play small contributory roles.
equate trephination of the donor button and the recipient bed. Use of sharp trephines and avoidance of changing trephine brands within the same surgical procedure are strongly recommended.16 Dull trephines, which may create irregular edges and affect the circularity of the donor and recipient buttons, have been associated with high degrees of astigmatism postoperatively.13,17
currently supplied in the form of corneoscleral rims. Trephination of the donor button can be performed from the epithelial side (anterior trephination) or the endothelial side (posterior trephination). Currently, most corneal surgeons prefer to perform donor button trephination with the endothelial side up. The donor graft is placed in a curved Teflon block with centration holes helping to place the donor graft centrally. A vertically guided punch device is used to obtain a circular button with vertical and regular edges. Artificial anterior chambers are currently used to cut donor grafts from the epithelial side using Krumeich or Hanna trephines. In theory, anterior trephination provides identical donor and host buttons if a same-size trephine is used for both trephinations and the pressure in the anterior chamber is equal to that in the recipient eye.7 An oval corneal donor button is considered an important factor in post-keratoplasty astigmatism. Tilted trephination has the potential to produce an oval button, in which more corneal tissue will be physically added along the longer diameter. Hence, the given axis will be flat and the meridian of the shorter diameter will be steep, creating an astigmatic surface.18,19 Eccentric trephination of the donor graft may play a role in postoperative astigmatism.20 The center of the recipient cornea should be marked accurately by a caliper, and a trephine should be placed perpendicular to the plane of the host cornea and equal pressure should be applied. Various techniques have been demonstrated for trephination of the recipient bed including freehand, suction, automated, mechanized, and video-guided devices.7 Ideally, the trephine is used to create a round and regular wound up to Descemet membrane. A diamond knife is then used to enter the anterior chamber, and a curved corneal scissors is used for the remaining cut. Eccentric trephination causes high post-keratoplasty astigmatism as it flattens the corneal meridian along the axis of displacement.20 Tilted trephination should be avoided because it can cause asymmetric corneal grooves and an oval recipient bed.19,21 An oval recipient bed is thought to be a key factor in post-keratoplasty astigmatism.10,19 A decreased or increased posterior circumference compared with the anterior epithelial
Host Bed Trephination
Intraoperative Factors Intraoperative factors are primarily related to trephination of the donor button and the host bed, but other factors also play a role. Application of eye speculum, lid retracting sutures as an alternative to eye speculum, and scleral rings can put pressure on the globe and lead to corneal distortion.15 Thus, although a perfectly round trephination may be obtained, it may assume an oval shape when the sutures or instruments are removed. Trephination is the most important step in corneal graft surgery. The trephination-related factors relative to postoperative astigmatism include sharpness of the trephine, trephination techniques, grafthost size discrepancy, and eccentric trephination or tilted trephination of the donor button and/or the recipient bed.
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circumference may occur during irregular scissor cuts of the host wound; thus, a certain degree of astigmatism may present.10 buttons and recipient beds on post-keratoplasty astigmatism is controversial. Many authors report no significant effect on astigmatism when over-sized grafts are used.13,22,23 However, Perl et al.24 suggest that oversized grafts increase astigmatism postoperatively compared with same-sized grafts. Oversized grafts may reduce hyperopia and are widely preferable because of their advantages of less wound leak and less incidence of glaucoma. Under-sized and same-sized grafts are recommended to address post-keratoplasty axial myopia in keratoconic eyes.25 Graft diameters between 7.0 mm and 8.5 mm do not appear to influence astigmatism significantly.26 Large graft diameters induce less astigmatism but are associated with a high risk for vascularization and allograft rejection. Small grafts are associated with larger amounts of astigmatism.27
Wound Apposition Wound apposition and healing play a significant role in post-keratoplasty astigmatism. Identical thickness of the donor button and the recipient bed provides perfectly apposed corneal layers. However, grafthost thickness disparity and underride/override of the graft are important factors that contribute to poor wound apposition. This can induce astigmatism because of the alteration in the surface vector forces.28 Careful alignment of the epithelial edges of the graft and the host should be obtained. Suturing Technique and Suture Material The suturing technique is one of the most studied factors in controlling post-keratoplasty astigmatism. Various patterns have been described, including interrupted sutures, continuous running sutures (single or double), and combined interrupted and continuous running sutures. Although some authors report the highest astigmatic outcomes with interrupted sutures technique,29,30 selective suture removal early postoperatively provides astigmatism reduction and early visual rehabilitation.31,32 Final astigmatism is almost the same with single running suture and double running suture techniques.33 Other authors have shown that an adjustable single running suture is better than a double running suture in managing postsurgical astigmatism.34 Busin et al.30 report that double running sutures with 16 bites each are superior to 16 interrupted sutures or double running sutures with less than 16 bites in minimizing astigmatism postoperatively while sutures are in place. It has been suggested that the single running suture technique induces less astigmatism than the combined method. However, Karabatsas et al.35 report Graft Size The effect of disparate size between corneal
no significant difference in the post-keratoplasty astigmatism between the adjustable single continuous suture and combined continuous and interrupted sutures at 1 year. Recently, Javadi et al.36 have shown that postkeratoplasty astigmatism is fairly comparable with the 3 common suturing techniques. Intraoperative suture adjustment increased refractive stability and minimized final astigmatism when all sutures were removed compared with postoperative suture adjustment.37 One more important point that surgeons should consider is the alignment of interrupted sutures, especially the second one. Standard teaching of graft suturing often states that the most difficult suture to place is the first suture, as the donor button is free and not fixated at any point. However, the most important suture is the second one as this determines the magnitude of astigmatism. It should be placed so it is in perfect alignment with the first suture (12:00) and bisects the donor tissue accurately into 2 halves. It should also be passed exactly at 6:00 of the recipient bed to ensure that the donor tissue is equally distributed to both sides of the middle vertical meridian of the graft and host. Let us assume that the first suture is placed at 12:00 and the second suture goes through the donor tissue at 6:00 exactly. If the second suture is placed at 5:30 on the host (and not 6:00), there will be more tissue on one half than on the other. This will cause permanent astigmatism. In other words, sutures should go out through the recipient tissue at the same clock position they are passed through in the donor button. This can be achieved by marking the recipient tissue prior to trephination, enabling the suture to be passed at the exact site. Three types of suture material have been used in corneal transplantation: monofilament nylon, polyester (Mersilene), and polypropylene (Prolene). Nylon sutures are most commonly used because of their elastic properties, which enable considerable compression or contraction of the wound.15 In contrast, some authors report that nylon sutures tend to break and cause more corneal astigmatic changes.38,39 Others report that polyester sutures are more likely to have handling-related and tissue-related complications than nylon sutures.40 Obviously, it is difficult to conclude from previous studies which materials and techniques are superior in terms of inducing less astigmatism. We prefer interrupted sutures or combined continuous running and interrupted suture techniques to get the advantage of selective interrupted suture removal in the early postoperative period to manage astigmatism. Postoperative Factors Wound healing of the grafthost junction is one of the uncontrolled factors in postsurgical astigmatism.
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Poor and unequal wound healing contributes to astigmatism after corneal transplantation.11,41 Many postoperative factors, including postoperative drugs such as steroids and immunosuppressive drugs, inflammation, corneal vascularization, rejection, and wound dehiscence, affect wound healing and may be associated with significant astigmatic changes. MANAGEMENT OF POST-KERATOPLASTY ASTIGMATISM The management of post-keratoplasty astigmatism takes place at 2 stages. The first is when sutures are still present at the grafthost junction, referred to as suture-in post-keratoplasty astigmatism. The second stage is when all sutures have been removed, referred to as suture-out post-keratoplasty astigmatism. Spectacle Lenses and Contact Lenses Spectacle lenses and contact lenses can play an important role in the management of astigmatism at all timepoints following corneal grafts. They are equally applicable to the management of suture-in and suture-out post-keratoplasty astigmatism. Although 3 diopters (D) or less of astigmatism after corneal surgery can be addressed by spectacle lenses, irregular astigmatism or significant anisometropia limits their use after keratoplasty. In one-eyed patients, even higher degrees of astigmatism can be corrected by spectacle lenses. Rigid contact lenses can provide better quality of vision, especially in patients with irregular astigmatism. Often patient choice determines the use of spectacles or contact lenses. Contact lenses are safe to use in the presence of sutures, which should not be a contraindication for prescribing them. Corneal surgeons prefer to prescribe contact lenses in cases with regular astigmatism of more than 3.0 D, irregular astigmatism, anisometropia, or aniseikonia.42 However, corneal abnormalities, dry-eye syndrome, fitting-related inconvenience, and lifestyle problems are major concerns that may affect a patients contact lens tolerance. The diameter of the graft, the topographical relationship between the host cornea and donor cornea, the graft toricity, and the location of the graft are essential parameters in contact lens fitting.42 Various types of contact lenses have been used to manage post-keratoplasty astigmatism including hybrid, scleral, rigid gas-permeable, and piggyback contact lenses. Toric intraocular lenses (IOLs) are a recent addition.43 Suture-in Post-Keratoplasty Astigmatism Regular postoperative follow-ups with topographyguided suture manipulation, including selective suture removal and/or suture adjustment along the steep (semi) meridian of astigmatism are the key factors to control astigmatism postoperatively.
The concept of selective removal of interrupted sutures was introduced by Cottingham in 1980.A Further investigators adopted this technique to manage astigmatism after corneal transplantation.28,32,44 More recent studies report the effect of suture removal on postkeratoplasty astigmatism.31,4547 In this technique, tight suture(s) is removed and the corresponding steep semimeridian(s) flattened. Refraction, keratometry, and topography are useful tools in determining the suture(s) that should be removed if the astigmatism is regular. Nevertheless, topography is superior to refraction and keratometry in the case of irregular astigmatism, as it provides information on steep semimeridians.48,49 When the steep axis of astigmatism determined by topography corresponds with the steep axis determined by refraction, the effect of suture removal is maximal. When the steep axis determined by these 2 methods differs, the effect of suture removal is variable.48 The timing of suture removal and the number of sutures that could be removed at each visit is an interesting debate. The longer the sutures remain in place, the less likely the chances of wound-related problems. However, in elderly patients on long-term topical steroids, the healing may not be adequate. It has been reported that the maximum effect of selective suture removal is in the early postoperative period and less astigmatic change will occur if suture(s) are removed 1 year after surgery,28 but many authors have demonstrated large astigmatic changes up to 6 years postoperatively.46,50,51 By 6 months postoperatively, most wounds are secure enough to allow removal of one or more pairs of interrupted sutures. In a recent study,31 corneal topography performed 30 to 45 minutes after suture removal indicated the next set of sutures to be removed for the remaining astigmatism with considerable accuracy. Therefore, a second set of sutures could be removed at the same follow-up visit of corneal graft patients.31 This reduces the number of follow-up visits and shortens the visual rehabilitation period (time to final spectacle or contact lens prescription) for those patients. Finally, it is our experience and recommendation that the knot should not be buried in the grafthost junction. If the knot is buried in the grafthost junction, it would stress the wound and increase the risk for dehiscence during removal. At times, it will produce an internal dehiscence of the wound and induce alteration in curvature. When removing sutures, the suture should be cut such that the knot does not have to traverse the grafthost junction for the same reason (Figure 1).
Selective Removal of Interrupted Sutures Suture Adjustment Adjustment of running sutures was first reported by Roper-Hall52 after intraocular surgery
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Figure 1. Interrupted suture removal. A: The knot is buried in the donor side, and the suture should be cut from the far side of the knot (arrow). B: Pulling the suture from the long-arm side (arrow) avoids traversing the knot through the grafthost junction.
or trauma. Later, it was applied by McNeill and Wessels53 to reduce astigmatism in keratoplasty patients. The technique is based on loosening the running suture in the steep meridian and tightening it in the flat meridian. This redistributes the tension of the suture evenly along the entire circumference of the wound.47 Many authors have reported successful results with this technique.34,54,55 Suture adjustment can take place as early as 1 day and up to 6 weeks after surgery because there is no weakening effect on the wound integrity.34 It is reversible, more predictable, and requires fewer suture manipulations postoperatively than selective suture removal.47,55 This technique can be performed under a slitlamp using tying forceps; however, achieving the correct suture tension requires expertise. Potential problems such as leakage, infection, or wound recession may occur because of corneal wound disruption.47,55 Suture breakage may also occur, and replacing a new suture may be required.53 In the double continuous suture technique and if the astigmatism cannot be managed by spectacle lenses or contact lenses, the deeper and the tighter of the 2 10-0 nylon continuous sutures can be removed.56 The 10-0 nylon suture should be removed when the technique involves 11-0 and 10-0 nylon sutures.57 The second suture should be left in place to support the wound and prevent dehiscence. Suture-out Post-Keratoplasty Astigmatism The general rule is that all sutures should be removed, ensuring stable topography and refraction before undertaking any surgical intervention. Astigmatic Keratotomy Astigmatic keratotomy (AK) is an established method of addressing high degrees of postkeratoplasty astigmatism that cannot be managed by spectacle lenses or hard contact lenses.58 Various AK techniques have been reported, but transverse incisions and arcuate incisions are the most popular.59 We prefer arcuate incisions, as each point on the
incision is at a uniform distance from the visual axis. This avoids an uneven distribution of force on the corneal architecture.60 The main principle of AK is based on flattening the steep corneal meridian by placing 1 or 2 incisions perpendicular to the steep axis. This flattens the given meridian with reciprocal steepening of the meridian 90 degrees away, known as a coupling effect.58 Various methods of performing AK incisions are currently available. These include freehand techniques,58,61 mechanical techniques using devices such as the Hanna arcitome,62 and femtosecond laser ablations.63,64 Incisions can be placed in the donor graft button,58 in the host cornea,65 or in the grafthost junction.66 The number of incisions, incision length and depth, and patient factors contribute to the outcome of AK.67 Moreover, the effect of AK may be augmented by compression sutures. Compression sutures can be placed across the flattest meridian to increase the curvature of the cornea, enhancing the surgical effect.68,69 Astigmatic keratotomy spares the visual axis and provides rapid visual rehabilitation. However, poor predictability, corneal perforation, and wound dehiscence are major concerns.7 We prefer to place arcuate incisions central to the grafthost junction at the 7.0 mm optical zone for maximal effect (Figure 2). Wedge Resection Corneal wedge resection was developed by Troutman70 to correct high post-keratoplasty astigmatism. In this procedure, a wedge of corneal tissue is excised from the donor or the host cornea along the flattest meridian, and the shortened tissue is apposed with tight sutures causing steepening. The excision can be performed by a femtosecond laser or manually by using a double-bladed diamond knife or a V-shaped knife.71 The 2 sides of the excision are then sutured with 10-0 nylon sutures, which should be tightened enough to induce initial overcorrection by 30% to 50% (Figure 3).7,71 Several factors affect the refractive outcome of wedge resection including the width, length, depth,
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Figure 2. With-the-rule astigmatism. Arcuate incisions along the steep vertical meridian with compression sutures along the flat horizontal meridian.
Figure 3. Against-the-rule astigmatism. Corneal wedge resection along the flat vertical meridian.
and location of the excised corneal tissue. Larger amounts of astigmatic correction are achieved by increasing the width of the excision, every 0.1 mm of resected tissue corresponding to approximately 1 to 2 diopters.72 Most clinical studies have reported that wedge resection is a safe and moderately effective treatment for post-keratoplasty astigmatism. Nevertheless, low predictability is a major concern with this procedure.7377 The manual technique of wedge resection is difficult and requires expert skill. In particular, the second incision is more difficult because the cornea is more flaccid as a result of the first incision. Excising the exact amount in depth and width is a challenging problem. Recently, the femtosecond laser has been applied to create corneal wedge resections. It theoretically provides more precise and accurate incisions, increasing predictability compared with the manual technique.71 Wedge resection is currently reserved for grafted eyes with high degrees of astigmatism, usually in excess of 10 diopters. Excimer Laser Excimer laser refractive surgery is another option to treat post-keratoplasty astigmatism. This technology offers the advantage of treating myopia, hyperopia, and astigmatism, while incisional techniques can address the astigmatic component only and do nothing to the spherical component. Photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) are the most common procedures demonstrated to correct post-keratoplasty astigmatism. Recently, laser-assisted subepithelial keratectomy (LASEK) has been reported to effectively reduce refractive errors in eyes with previous keratoplasty.78,79 Patients with
early signs of graft rejection, recurrent herpetic disease, or any other inflammatory condition are contraindicated for laser refractive surgery treatments. The successful use of PRK for the correction of primary astigmatism and myopia has encouraged corneal surgeons to apply this method after keratoplasty.8083 However, performing PRK after corneal graft surgery has variable outcomes with a high rate of haze and scar formation postoperatively.80,82,84,85 Mitomycin-C (MMC) is often used during surface ablation procedures to prevent haze by modifying the corneal wound-healing process.86,87 A recent metaanalysis showed that MMC led to significantly less corneal haze in PRK. However, using MMC provided no advantage in LASEK and epithelial laser in situ keratomileusis.88 In addition, corneal graft rejection has been reported after PRK.89,90 Laser in situ keratomileusis has the advantage of correcting a wider range of spherical errors and astigmatism than PRK, and it provides effective and predictable refractive outcomes following keratoplasty.9195 Although LASIK reduces the risk for postoperative haze and corneal scarring compared with PRK, some potential complications are associated with flap creation.9698 Other adverse events include ectasia, dry-eye syndrome, epithelial ingrowth, and diffuse lamellar keratopathy.99 Currently, LASIK for post-keratoplasty patients can be carried out in 2 ways. Some surgeons claim significant astigmatic changes after cutting the flap, so they would create a lamellar flap in one session and allow it to heal for a certain period of time. The flap will be lifted and laser ablation applied in a second session. This approach is known as 2-step LASIK.91,100 However, this approach potentially increases the rate of
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epithelial ingrowth and haze postoperatively compared with 1-step LASIK.101 The femtosecond laser offers more accurate, uniform, and thinner flaps than mechanical microkeratomes.102,103 Moreover, wavefront-guided treatments and refined treatment algorithms may provide optimum refractive outcomes. Toric Intraocular Lenses Toric IOLs are also used to correct astigmatism.104 They provide a wide range for correction of spherocylindrical errors and require less manipulation of the grafted tissue. This modality may be a good choice when keratorefractive procedures are contraindicated in post-keratoplasty patients with cataracts, corneal thinning, and corneal ectasia. Toric IOL implantation has been described to correct post-keratoplasty astigmatism in phakic eyes or at the time of cataract surgery. Frohn et al.105 were the first to describe toric IOL implantation in a patient with cataract for correction of high post-keratoplasty astigmatism. Later, Alfonso et al.106 reported that toric posterior chamber phakic IOLs are a viable treatment option for myopia and astigmatism after keratoplasty. Furthermore, Tahzib et al.107 noted that the implantation of toric iris-clip IOL after keratoplasty is effectively reduces astigmatism and ametropia in phakic and pseudophakic eyes. Surgically induced astigmatism (SIA) resulting from toric IOL insertion is a potential limitation of this modality, especially with implantation of the rigid poly(methyl methacrylate) IOL through a 5.5 mm incision. Although this SIA is believed to be more unpredictable and greater in grafted corneas than in native corneas, it may be acceptable as the aim of managing astigmatism after corneal grafts is to reduce refractive ametropia, including astigmatism, to a degree that can be managed by spectacle lenses or contact lenses. Nuijts et al.108 report a mean SIA of 1.85 D. A later study reports a mean of 2.53 D after toric IOL implantation following keratoplasty.107 Hopefully, new foldable toric IOLs requiring smaller incisions will result in less SIA. Endothelial cell loss is another concern about this treatment modality. In contrast to implantation of toric IOLs for correction of naturally occurring ametropia, a higher rate of endothelial cell loss has been reported after correction of post-keratoplasty ametropia by toric IOLs.106109 This is probably due to the natural loss after corneal transplantation, which has been reported to be 7.8% from 3 to 5 years and 4.2% from 5 to 10 years post keratoplasty.110112 Other concerns include chronic inflammation, cataract formation, and cystoid macular edema. Another challenge may confront corneal surgeons if the corneal graft fails and another graft is indicated. In
the case of toric posterior chamber phakic IOLs or pseudophakic toric IOLs, implantation of another IOL in the anterior chamber (iris-clip IOL) may address the astigmatic change after the second graft. In some cases, repositioning the toric IOL can be considered to correct the astigmatism induced by the second (or subsequent) graft. Otherwise, explantation of the IOL, especially in the case of iris-clip IOLs, should be considered. This is likely to be the most viable and effective option in many cases but is easier said than done. The best option will have to be considered on a case to case basis. FUTURE OF KERATOPLASTY Recent advances in technology involve the use of the excimer laser and femtosecond laser to cut donor buttons and recipient beds. This ensures better apposition of the graft with the host bed and produces regular and smoother edges of donor and recipient tissues. These more exact and matching profiles of donor and recipient are expected to reduce significantly the occurrence and magnitude of post-keratoplasty astigmatism. These profiles include the top-hat, mushroom, zig-zag, and Christmas tree shapes.113 Few authors reported less than 3 diopters of astigmatism following femtosecond PKP in short-term follow-ups.114116 These values were less than those reported after mechanical PKP.117,118 A comparison study noted more post-keratoplasty astigmatism in conventional trephination versus zig-zag-shaped incision by the femtosecond laser.119 The femtosecond laser also allows the surgeon to obtain a smooth and regular lamellar plane in lamellar keratoplasty. The popularity of endothelial transplantation techniques has eliminated the occurrence of induced astigmatism as host-bed trephination and use of sutures to secure the endothelial graft are not required. In a report of data extracted from 18 studies by the American Academy of Ophthalmology,120 the authors demonstrated that DSEK was a relatively astigmatism-neutral surgery. The mean astigmatism after DSEK was 1.5 D, with SIA ranging from 0.4 to 0.6 D, with a mean of 0.11 D of induced astigmatism. Recently, Guerra et al.121 reported a reduction of 0.16 D in the negative cylinder 12 months after DMEK. There was no statistically significant difference between the preoperative and postoperative DMEK. REFERENCES
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First author: Usama Fares, MD Division of Ophthalmology and Visual Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom