Care for post-PK patients key to graft survival

Grand Rapids, MI-Just as the preoperative evaluation of patients about to undergo corneal transplantations involves numerous factors, so does the postoperative management of patients who have undergone these procedures, especially penetrating keratoplasty (PK). David D. Verdier, MD, outlined how to care for these patients with special emphasis on corneal surface problems, which he believes are responsible for a high percentage of graft failures.

Fourth-generation fluoroquinolones are the antibiotics of choice following corneal transplantations. The usual regimen is four times daily for 7 days.

"We hope by the end of the administration of the antibiotics, epithelialization has occurred. If it has not occurred, it is pursued aggressively. I continue the antibiotics twice a day until epithelialization occurs," Dr. Verdier said.

"If the patient is not phakic, this drug will be continued indefinitely because of the ongoing risk of rejection of the graft," Dr. Verdier explained. He is in private practice in Grand Rapids, MI.

Corneal surface problems

Dr. Verdier explained that after doing corneal transplantations for 15 years, he has found that the biggest problem early in the postoperative period is the corneal surface.

"We think that transplants fail because of rejection. However, probably half of our transplants fail because of surface problems," he explained. "The simplest approach is the application of a nonpreserved ointment four times a day. The patients don't like to do it. However, I use it for at least the first month postoperatively and often the first year after the surgery depending on whether they have punctate keratitis, and if it is winter in Michigan I will definitely continue application of the ointment during the less humid months."

Aftercare also involves very frequent examinations-up to 6 or 7 times minimum during the first year and very frequently in the early postoperative period.

"It is important to keep seeing these patients at least every 6 to 8 months until all the sutures have been removed. They can come in asymptomatic with suture-related problems," he said.

During reexaminations after the first year, he looks for signs of late endothelial failure or rejection of the graft.

Reemphasizing the importance of meticulous management of the corneal surface after transplantations, he stated, "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 neurotrophic because the nerves have been cut, and there is uneven spreading of tear film, because of abnormal tissue contour," he said. Cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) may be helpful in some of these patients.

If patients do not show signs of reepithelialization within 1 week after the surgery, Dr. Verdier often inserts punctal plugs; he prefers to use ones that are visible and that do not dissolve. If reepithelialization 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," he said. "Suture tarsorrhaphy can be performed in an office setting. This procedure is much underutilized; by the time it is performed it is often about a week later than it should have been done."

Suture care

Most of the sutures holding the corneal graft in place should be left in place to provide support for at least 9 to 12 months. The older the patient is, the longer the sutures need to be left in place, he noted. In contrast, in infants the sutures may have to be removed in 2 to 4 weeks.