Clinical outcome of sequential bilateral pediatric penetrating keratoplasty (PKP) in patients with corneal dystrophies in South India

Clinical outcome of sequential bilateral pediatric penetrating keratoplasty (PKP) in patients with corneal dystrophies in South India Dear Editor, Penetrating keratoplasty (PKP) in pediatric corneal blindness (<18 years of age) is the standard surgical procedure for visual rehabilitation in full thickness corneal scarring and to avoid deprivation amblyopia. 1ongenital corneal opacities account for higher number of pediatric PKP in the western world as compared to India where it's more of corneal leucoma post microbial keratitis. 2Congenital hereditary endothelial dystrophy, congenital glaucoma and macular corneal dystrophy (MCD) are the more common indications for pediatric PKP in the gulf, middle east countries because of higher rate of consanguineous marriages. 3,4l-Ghamdi et al. from Saudi Arabia reported as high as 80% of pediatric PKP performed for congenital opacities out of which 2/3rd was because of congenital glaucoma & CHED. 4 CHED should be differentiated from congenital glaucoma as has been cautioned in the reports of misdiagnosis. 5ediatric PKP is a surgical challenge due to difficult pre-operative work up and intra-operative hurdles like smaller eyes, positive posterior pressure, frequent post-operative evaluation under anaesthesia. 6,7However, bilateral PKP in paediatric age group has shown favourable results in recent times. 8,9The prognosis of corneal grafting has improved due to the ever-improving quality of eye banking, advancement in surgical techniques, improved management of complications.However, there is limited literature on the outcome following sequential bilateral pediatric PKP in patients with corneal dystrophies in India.We retrospectively analysed the visual outcome, graft clarity and complications following sequential bilateral paediatric PKP for corneal dystrophies performed at our centre in Southern India.This was a retrospective, observational study which included 32 eyes of 16 pediatric patients (<18 years) with corneal dystrophy who underwent bilateral PKP between August 2016 to June 2019 and follow up for at least one year post second eye surgery.Unilateral keratoplasty, lamellar and therapeutic keratoplasty and patients with less than 1 year of follow up were excluded.Preoperative workup included demographic, best corrected visual acuity (BCVA) and ocular examination findings.The indication for keratoplasty, details of the surgery and of any additional procedure were recorded.Examination under anaesthesia was done in younger, uncooperative cases and pre op.intravenous mannitol (1 gm/kg body weight) was given in most patients.Post-operatively, outcome, graft clarity, complications, were recorded and analysed.The eye with better visual potential was operated first.The donor graft size was oversized by 0.5 mm and 10-0 nylon monofilaments sutures (Ethicon) were used for suturing.Flieringa ring was used in many cases to avoid possible globe collapse due to low scleral rigidity.Suture removal was done any time from 7 months to 1 year, and early suture in MCD has graft survival recorded to be as high as 87%-92%. [10][11]][12] Graft rejection was the most common of complications encountered post PKP (50%) followed by secondary glaucoma, graft failure, keratitis (fungal), cataract and graft dehiscence(Table 2 a).This is similar to