Autologous Penetrating Keratoplasty- The ‘Perfect’ Candidate?

To present a case of what we consider to be the ideal patient for successful autologous penetrating keratoplasty (APK).

The case presented herein was managed at Shrewsbury Hospital, a part of Shrewsbury and Telford NHS Trust, which caters for a population of approximately 300,000 people. The Ophthalmology unit has one full-time corneal consultant who managed this particular case.

Mr R, a gentleman in his 70s, with known hand motion (HM) vision in his left eye (LE) secondary to herpetic corneal scarring unfortunately developed right eye (RE) periorbital necrotising fasciitis. Despite making a good recovery systemically with prompt surgical debridement and intravenous antibiotics, he was left with no-perception-to-light (NPL) vision in his RE secondary to compressive optic neuropathy. His RE cornea remained healthy.  Mr R was keen to resume driving once again and therefore consented for autologous penetrating keratoplasty (APK) to restore vision to the LE. Surgery was uneventful. Initially, a four week course of preservative-free topical dexamethasone 0.1% four times daily was prescribed but then extended due to ongoing mild inflammation. Fortunately, there has been no recurrence of herpes simplex keratitis at this stage. Currently, he is two months post-APK and very happy with the outcome having achieved 6/36 vision whilst awaiting fitting of contact lenses. He looks forward to hopefully driving once again.

Autologous PK- or swapping the corneas, significantly reduces the need for post-operative steroid use (since there is negligible risk of rejection) and consequently minimises the risk of flare of quiescent herpes simplex keratitis. The few reports of APK have shown promising long term outcomes (>12 months), including in those with co-pathology^1,2. Mr RA is potentially the ‘perfect’ candidate for APK since his donor RE had NPL vision with a healthy cornea and recipient LE was overall healthy other than extensive anterior corneal scarring. These criteria are seldom met, and so far has shown a favourable outcome.