Penetrating Keratoplasty Management In Neurotrophic Keratopathy And Central Leukoma Due To Herpes Infection

To describe the complications and management of a patient with corneal penetrating keratoplasty (PK) due to herpetic leukoma, and to highlight the importance of corneal sensitivity in the prognosis of these transplants.

Herpes keratitis is one of the main causes of needing a corneal transplant, due to the secondary opacities. However, it is also one of the main causes of corneal anaesthesia, thus making it difficult to manage. Compromised corneal sensitivity can not only condition the epithelialization of a previous penetrating or lamellar corneal transplant graft, but also be related to a progressive stromal thinning of the graft until its perforation.

A 64-year-old woman came to evaluate a corneal transplant in her left eye (LE). She referred dry eye disease, corneal infection at 10 years old, neurothophic ulcer 11 years earlier and amniotic membrane implant 6 years earlier, all in LE.

She had: visual acuity (VA) 0.9 in right eye (RE) and 0.1 in LE; corneal sensitivity normal in RE and decreased in LE; central leukoma in LE; intermediate retinal drusen in both eyes. Intraocular pressure was normal and lens was transparent.

A PK was performed, which epithelialized correctly at one-week control. However, in subsequent exams she presented neurotrophic ulcer that didn't heal despite intensive lubricating treatment, bandage contact lens (BCL) and topical antibiotic, and progressive thinning of graft stroma. A second PK was recommended but patient went to a private centre to perform a combined surgery (PK and cataract surgery) and returned later. Throughout the follow-up of this second graft, the following complications occurred: central herpetic ulcer, crystalline keratitis, PED, progressive stromal thinning, Candida guilliermondii infiltrate, and stromal rejection. Specific treatment of each complication was carried out, leading to a third PK. Finally, the case was controlled by definitive tarsorrhaphy and chronic treatment with insulin eye drops, cyclosporine A eye drops, topical preservative-free dexamethasone, lubrication, and oral valacyclovir. The patient remains without BCL and her corrected VA is 0.9 in RE and 0.5 in LE.

Corneal sensitivity has a vital role in the prognosis of PK transplants. A good previous examination and a correct postoperative management can determine the success of the procedure.

In compromised corneal sensitivity cases, the reduction of the palpebral fissure by tarsorrhaphy may help in the control of PED, neurotrophic ulcers, and progressive stromal thinning.

In addition, insulin eye drops have shown: to be an effective weapon in PED management, good tolerance, low production cost, and its chronic use does not seem to produce adverse effects.