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Results of Penetrating Keratoplasty in Syphilitic Interstitial Keratitis

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Results of Penetrating Keratoplasty in Syphilitic Interstitial Keratitis RESULTS OF PENETRATING KERATOPLASTY IN SYPHILITIC INTERSTITIAL KERATITIS GOEGEBUER A.*, ***, AJAY LOHIYA**, ***, CLAERHOUT I.*, KESTELYN PH.* ABSTRACT ratite interstitielle (KI) syphilitique avec ceux dé- crits dans la litérature. Purpose: To compare the results in our patient se- Méthode: Analyse rétrospective des cas, avec acui- ries after penetrating keratoplasty (PKP) for syphi- té visuelle, clarté du greffon, épisodes de rejet, pres- litic interstitial keratitis (IK) with those described in sion intraoculaire et comptage postopératoire des the literature. cellules endothéliales. Methods: Retrospective case series in which visual Résultats: L’acuité visuelle s’est améliorée dans tous acuity (VA), graft clarity,rejection episodes, intraocu- les cas. Il n’y avait pas de signes de déhiscence du lar pressure and endothelial cell density (ECD) were greffon, ni d’ occurrence d’une membrane rétrocor- examined postoperatively. néenne. L’inflammation postopératoire n’était pas Results: Postoperative VA improved in all cases. plus prononcée chez nos patients avec une kératite There was no evidence of wound dehiscense or oc- interstitielle comparée aux patients opérés pour currence of retrocorneal membrane formation in any d’autres raisons. Un déclin normal du comptage des case. Postoperative inflammation was not more se- cellules endothéliales prouvait qu’il n’y avait pas d’in- vere in our patients with syphilitic IK compared to flammation infraclinique. patients undergoing PKP for other reasons. A nor- Conclusion: Une kératoplastie transfixiante pour KI mal decline in ECD proved that there was no sub- syphilitique a un bon pronostic en ce qui concerne clinical inflammation as well. la clarté du greffon. Tous les patients bénéficiaient Conclusion: PKP for syphilitic IK has a good prog- d’ une amélioration de l’acuité visuelle, bien que par- nosis in our case series as far as graft survival is con- fois limitée. Nous rencontrions moins de complica- cerned. Improvement in VA was present in all cas- tions postopératives chez nos patients que dans les es, though sometimes limited. In our case series, we séries décrites dans la litérature ancienne, ce qui est experienced less postoperative complications than probablement du a l’évolution des techniques mi- described in the older literature, which is probably crochirurgicales. due to better microsurgical techniques used nowa- days. KEY-WORDS Penetrating keratoplasty, syphilitic interstitial RÉSUMÉ keratitis, postoperative inflammation, But: Comparer les résultats obtenus chez nos pa- endothelial cell density tients après une kératoplastie transfixiante pour ké- MOTS-CLES Kératoplastie transfixiante, kératite zzzzzz interstitielle syphilitique, inflammation * Department of Ophthalmology, Ghent University postopératoire, comptage des cellules Hospital, Belgium endothéliales. ** Department of Ophthalmology, LTMMC & LTMGH, Sion, Mumbai, India *** Both authors contributed equally received: 16.07.03 accepted: 16.09.03 Bull. Soc. belge Ophtalmol., 290, 35-39, 2003. 35 INTRODUCTION membrane (5). We compared our results after PKP for syphilitic IK with those described in Although syphilis has become rare, it still is an literature. existing cause of ocular disease. Syphilis is a multi-system, multi-symptom dis- order, caused by a spirochete, Treponema pal- MATERIALS AND lidum, that occurs primarily through sexual trans- METHODS mission, but can also be spread through blood transfusion or direct contact with an infected We retrospectively studied six cases of pene- lesion. Transplacental transmission leads to con- trating keratoplasty, performed on five eyes of genital syphilis. Clinically, if untreated, acquired four patients with syphilitic interstitial keratitis syphilis may follow three classic stages: pri- (one patient had bilateral grafts, and had a re- mary, secondary and tertiary syphilis. In cases graft in one eye) and reviewed the literature of congenital syphilis, patients may manifest concerning this subject. Hutchinson’s triad: interstitial keratitis, deaf- The diagnosis of syphilitic interstitial keratitis ness and teeth malformation. was based on the characteristic slit lamp find- In acquired syphilis, various inflammatory ocu- ingsofinterstitalkeratitis,combinedwithaposi- lar complications may occur in the secondary tive TPHA serology. or third stages: episcleritis, uveitis, glaucoma, The study group consisted of one male and three neuroretinitis, chorioretinitis, ischemic vascu- females aged between 39 and 71 years, with lopathy, infectious optic neuropathy, optic a mean age of 60 years. The average follow-up atrophy and pupil abnormalities. period was 42 months, with a range between Interstitial keratitis (IK) is a typical manifesta- 31 and 50 months (median: 40 months). tion of congenital syphilis (4), but may rarely Donor corneal buttons preserved in organ cul- occur in acquired syphilis. The active keratitis ture at 31°C, with an endothelial cell density begins with a corneal infiltrate, uveitis and of at least 2200 cells/mm2, were used for graft- Descemet’s membrane alterations. This ing. In all cases, the graft size was 7.25 mm progresses to heavy superficial and deep vas- for donor and 7.00 mm for recipient cornea. cularisation, leading to the so called ’salmon Double continuous (10-0) non absorbable su- patches’. Clearing is associated with corneal tures were used in all patients. In two cases, thinning and ghost vessel formation. Chronic keratoplasty was combined with lens extrac- ocular signs of congenital syphilis include stro- tion and IOL implantation. Peripheral iridecto- mal scarring, ghost vessels and residual deep my was not done in any of the cases. vascularisation, cornea guttata, scrolls in De- scemet’s membrane, glaucoma, band keratop- Postoperatively, steroid eye drops were admin- athy, corneal thinning, lipid keratopathy and istered with tapering dosage for six months. Salzmann’s degeneration. Other late sequelae Systemic steroids were not used. of congenital syphilis include cataract, pigmen- All patients were followed-up weekly for the first tary retinopathy (salt and pepper fundus) and 3 weeks, then monthly for 6 months and then optic atrophy (7). 6-monthly for 3 years. On each follow-up visit, In cases of interstitial keratitis, therapeutic de- following examinations were done: visual acui- cision making is based on syphilitic disease ac- ty testing on Snellen’s chart, slit lamp biomi- tivity. Distinguishing between active and resi- croscopy, intraocular pressure measuring us- dual corneal disease is crucial when deciding ing applanation tonometry and fundus exami- to start a possible penicillin treatment (3). Pen- nation. etrating keratoplasty (PKP) is usefull in cases Endothelial cell counts were done 6 months af- of severe corneal opacification in quiet inter- ter surgery and then yearly thereafter with spec- stitial keratitis (8). Several problems after PKP ular microscope and compared to data obtained for syphilitic keratitis are reported in the liter- from a control group. The data from the con- ature: higher incidence of serious postopera- trol group were used to generate the expected tive uveitis (1) and glaucoma (2, 8), wound de- loss of ECD over the different time intervals in- hiscence (8) and rarely retained Descemet’s volved. 36 RESULTS in the control group are given as mean ± the standard deviation. Mean loss of ECD and stan- Patient characteristics at dard deviation were used to construct 90% ref- presentation: erence ranges at each time interval in the con- trol population (mean ± 1.64 times the stan- Preoperative slit lamp examination showed the dard deviation). A decline in ECD outside this presence of leucomatous corneae with ghost 90% reference range was considered signifi- vessels in all cases. One patient had miosis and cantly stronger than the expected decline. For band keratopathy. Another patient had exten- instance from transplantation to 6 months post- sive deep corneal vascularisation in both eyes, operatively the endothelial cell loss was 17% but also signs of an old uveitis with posterior with a standard deviation of 13. So a decline synechiae and a pigmentary retinopathy. over the six month period after the transplan- VDRL serology was positive in one patient, TPHA tation of more than 38% (17+1.64×13 gives was positive in all cases. 38%) was considered significantly stronger than expected. Similar reference ranges were con- Postoperative findings: structed for all time periods involved. Postoperative decline in endothelial cell densi- Three grafts of three patients remained clear on ty in our patient group was not significantly all follow-up visits. The fourth patient devel- stronger than that observed in the control group, oped an irreversible allograft rejection of the except for 1 patient (who had undergone 2 re- graft in her right eye nine months postopera- versible allograft rejection episodes). tively. She underwent a regraft in that eye one year later. A PKP was also performed in the left eye eleven months after the regraft in the right DISCUSSION eye. Both grafts underwent two reversible al- In this study we have examined the outcome lograft rejection episodes during the first post- of PKP in syphilitic interstitial keratitis. IK has operative year. On the last follow up visit, 50 classically been defined as a non suppurative months and 39 months postop respectively, infiltration of the corneal stroma, with stromal both grafts were clear. vascularisation. Years after active inflamma- In all eyes, the postoperative
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