Postoperative care: the key to successful corneal grafts

Just as the preoperative evaluation of patients about to undergo a corneal transplantation involves numerous factors, so does the postoperative management of patients who have undergone these procedures, especially penetrating keratoplasty (PK). Here David D. Verdier, MD, outlines the best way to care for these patients, placing special emphasis on corneal surface problems, which he believes are responsible for an alarmingly high percentage of graft failures.

Which antibiotic?

Fourth-generation fluoroquinolones are the antibiotics of choice following corneal transplantations. The usual regimen is four times daily for seven days. "Hopefully, by the end of the administration of the antibiotics, epithelialization has occurred. If it has not it is pursued aggressively. I continue the antibiotics twice a day until epithelialization does occur," Dr Verdier said.

Rejection often not the main reason for graft failure

It is often thought that transplants are most likely to fail because of rejection, but Dr Verdier, who has been performing the procedure for 15 years, says that this is simply not the case: "Probably half of our transplants fail because of surface problems." So what is the best way to pre-empt and deal with this? Dr Verdier recommends using a non-preserved ointment four times a day for the first month following surgery. Despite patients often not liking this method, he maintains that it is the best option and frequently uses it for up to a year depending on whether the subject has punctate keratitis.

After care also requires frequent examinations - a minimum of six or seven times during the first year and even more frequently during the early postoperative period. "It is important to keep seeing these patients at least every six to eight months until all the sutures have been removed as they can come in asymptomatic but with suture-related problems," he said. During re-examinations after the first year, he also recommends looking for signs of late endothelial failure or rejection of the graft.

Re-emphasizing the importance of meticulous management of the corneal surface after transplantations, he commented, "The corneal surface is the most important factor to pay attention to, especially in the first several weeks postoperatively. The corneal surface is under a great deal of stress in that it is neotrophic because the nerves have been cut, and there is uneven spreading of tear film, because of abnormal tissue contour." Cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) may be helpful in some of these cases.

If patients do not show signs of re-epithelization within one week of surgery, Dr Verdier suggests inserting punctal plugs; he prefers to use ones that are visible and that do not dissolve. If re-epithelization still has not occurred within 10 to 14 days, he then performs a suture tarsorrhaphy. "I believe that this approach works better than pressure patching, which we also sometimes use. Suture tarsorrhaphy can be performed in an office setting. This procedure is much under-utilized; by the time it is performed it is about a week later than it should have been done," he said.