Pediatric Penetrating Keratoplasty In A Tertiary Hospital Center: Clinical Profile, Visual And Anatomic Outcomes

Penetrating Keratoplasty (PK) is a complex eye surgery often used in pediatric patients with severe corneal pathologies. This technique presents particulary challenges in this group of patients, including difficulties in the preoperative assessment, intraoperative obstacles due to small eye size and reduced scleral rigidity, and demanding post-operative follow-up and management. Moreover, its success rates in children are lower compared to adults due to higher risks of rejection or failure. Our study aims to identify the indications, visual outcomes and overall graft survival rates following primary PK in a pediatric population.

Cornea and Pediatric Department of ULS São João, Porto, Portugal

We performed a retrospective study of primary PK in children aged 0 to 18 years between 2011 and 2021 in ULS São João, Porto. Demographic variables, surgical indications and preoperative BCVA were analyzed. Postoperative BCVA at 2 years, complications and overall allograft survival rate were examined 1 and 5 years postoperatively.

A total of 32 PK in 30 children (75% male) were submitted to primary PK. The mean age at the time of the surgery was 12.48 ± 5.74 years old. Keratoconus was the predominant indication for PK (50%), followed by corneal leukoma (21.9%) attributed to herpetic keratitis and trauma in the majority of cases. Mean BCVA improved from 0,88 ± 0,20 (LogMAR) to 0.28 ±  0.33 at 2 year follow-up (p-value 0.1). Mean follow-up time was 96.39 ± 40.57 months with an overall allograft survival rate of 93,5% at 1 year (N=31 PK) and 75,0 % at 5 years (N=24 PK). Allograft rejection was reported in 5 eyes in an average time of 26 months (ranging from 13 to 41 months), of which a second PK was required in 1 eye 20 months after the initial transplant. 

This study showed that primary PK emerged as a crucial intervention for addressing various corneal pathologies in children. Despite its success in improving visual acuity, particularly in keratoconus, challenges such as allograft rejection are still observed. Despite a low rate of retransplantation, the incidence of allograft rejection persisted over an extended time, highlighting the importance of long-term monitoring and management in pediatric PK. Extended follow-up studies are needed to strengthen evidence on surgical outcomes and graft survival in pediatric corneal transplantation. Additionally, exploring the viability of other surgical approaches, such as lamellar keratoplasty, holds promise in optimizing outcomes for these patients.