UNMASKING THE DONOR’S PAST: POST-REFRACTIVE CORNEAL GRAFTS AND EARLY PKP COMPLICATIONS

To describe early postoperative complications after penetrating keratoplasty (PKP) when donor corneas had unrecognized prior excimer-laser refractive surgery, and to highlight clinical and histologic clues that can prompt timely diagnosis and management.

Tertiary cornea service with routine PKP procedures; donor tissues were sourced through standard eye-bank screening and were not flagged for prior refractive surgery.

We present three PKP recipients whose donor buttons were later found to have undergone prior excimer-laser refractive surgery (not identified preoperatively or intraoperatively). Within the first postoperative month, all three developed atypical findings that compromised graft quality and vision: delayed epithelialization persisting >4 weeks, excessive central graft flattening (applanation), marked and unstable hyperopia, and anterior-segment OCT demonstrating central thinning of the button. Each case required early regrafting. Histopathologic analysis of the explanted buttons showed surface irregularity, stromal ablation morphology, and absence of Bowman layer, consistent with prior corneal laser ablation.

Unrecognized prior LASIK/PRK in donor tissue can precipitate early PKP failure. Be alert to the early warning pattern: (1) prolonged epithelialization delay, (2) central graft flattening, (3) large, unstable hyperopic shift, and (4) AS-OCT central thinning. Prompt recognition should trigger targeted imaging, consideration of donor-tissue replacement, and closer liaison with eye banks to refine screening protocols.