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Post-Operative Risk Factors, Complications and Preventive Solutions & Post-Op Drug Use

Post-Op Risk Factors

1. Persistent corneal epithelial defect

  • Artifical tears + antibiotics and observation
  • Bandage lens
  • Amniotic membrane
  • Temporary tarsorraphy (partially sew eyelids)

2. Bad interface of graft and bed

If the graft-bed interface is not smooth, it would affect wound healing, possible reasons

  • Graft or bed edema: observe or use bandage lens
  • Sutures not on the same level: remove sutures and suture again
  • Graft and bed thickness not equal: compensate the difference during suturing or use a different graft

3. Graft dissolution

  • Efficient re-epitheliallization is important for avoiding graft dissolution
  • Cover with amniotic membrane once graft dissolution is observed without infection
  • If amniotic membrane does not yield favorable results, perform temporary tarsorraphy
  • If the graft dissolution reaches deep stroma and cannot be salvaged, conduct the surgery again with a new graft

4. Loose sutures

  • Must be removed promptly
  • Whether or not new sutures are needed is dependent on the actual situation

Summary

  • Control of infection and recurrence of primary disease
  • Promote re-epithelialization
  • Control inflammation and immune response
  • Closely monitor for any complications and deal with any issues promptly

 

Post-op Complications

Preventive Solutions

Immunorejection

Routine recommend all patients to continue use of immunosuppressive agents for 6-12 months (such as cyclosporine A or tacrolimus), for patients that show early signs of immunorejection, combine adequate dosage of glucocorticoid.

Limbal hypervascular neovascularization; limbal microangiitis

Inhibition of corneal neovascularization (e.g. thalidomide); for patients with microvasculitis, use 0.5% heparin eye drops additionally. Recommend combined use with immunosuppressive agent to prevent graft dissolution

Activation of matrix metalloproteinase or collagenase, resulting in graft dissolution

Collagenase inhibitors: inhibit metalloproteinase activity and reduce or inhibit graft dissolution. Amongst the known collagenase inhibitors, GM6001 has the strongest inhibitory power.

Recurrence of infection leading to graft ulcer

Control infection, combine use of immunosuppressant and collagenase inhibitors

Loose sutures

Remove loose sutures in a timely manner. Redo sutures if required.

Post-op graft edema resulting in poor healing

Local use of 500g/L hypertonic glucose eyedrops to remove water, combine use with steroids and anti-infection medications if required

Excessive dehydration of the graft after surgery, resulting in gaps causing poor re-epithelialization

Continue due of artificial tears to keep the graft moist, do not rehydrate the graft excessively pre-op to prevent corneal edema; if the gaps are too large, consider conducting the surgery again.

Large graft or partial-centre transplantation

(Graft diameter ≥ 8mm)

When selecting cases, choose those with smaller lesions, as larger graft tend to have more issues with re-epithelialization, recurrent inflammation and neovascularization. Actively prevent neovascularization and immunorejection.

Post-op dry eye leading to poor healing of epithelium and affecting healing

Resolve dry eye and other tear-related abnormalities pre-op; better follow-up to observe epithelium healing and tear film post-op. Use artificial tears and corneal epithelial growth factors for patients with dry eye.

Poor post-op care causing mechanical injury (graft dislocation, detachment or ocular surface damage)

Improve post-op patient care and education; strict regular follow-up, increase frequency for less compliant patients. If inconvenient for patients to come back to the same hospital, go to local hospital for follow-up

Long-term overuse of glucocorticoids

Long-term use of glucocorticoids post-op can cause complications such as glaucoma, cataract, epithelial defects, ulcers or even perforation.

 

Post-Op drug use

Lamellar keratoplasty is a type of partial corneal transplant. Lamellar keratoplasty transplants the anterior lamina of the cornea. The incidence and severity of immunorejection are lower than those in penetrating keratoplasty, hence the drug use post-op is also different.

 A. Systemic drug use – Usually there is no need for systemic drug use unless combined with other ocular surgeries. If so, can consider systemic drug use for a short period of time post-op (no more than 3 days post-op)

 B. Local drug use

1. Routine anti-infection drugs used before the surgery, for infectious keratitis/ulcer both anti-infection drugs both before and after surgery;

2. Start use of mid-high concentration steroids post-op, e.g. 1% prednisolone acetate or dexamethasone;

3. One month post-op gradually reduce use of ocular surface steroids; start use of immunosuppressive agent post-op, e.g. FK506 or CsA, continue use for 6-12 months and gradually reduce dosage;

4. For patients with mild dry eye symptoms, recommend use of sodium hyaluronate post-op to prevent dry eye symptoms from causing poor healing of the epithelium then gradually transition to artificial tears.

C. Perioperative medication for corneal transplantation for infectious keratitis

1. Keratoplasty should be performed promptly if the condition of infectious keratitis continues to deteriorate and not healed;

2. In addition to pre-op and post-op prophylactic topical use of broad-spectrum antibiotics, patients with infectious keratitis should be sorted according to the type of infection (e.g. bacterial, viral, fungal, amoebic) and given the appropriate anti-infection medication;

 3. Recommended close follow-up ≥1month for the following infectious keratitis patients

1Use of anti-infection medication – viral infection

Stable phase infection:

  • Local and systemic antiviral prophylactic antiviral drug should be given, such as topical acyclovir ophthalmic solution and ganciclovir ophthalmic gel;
  • Systemic oral acyclovir tablets or ganciclovir capsules etc.;
  • Continue use of antivirals 1-3 months post-op, infection during active phase is usually accompanied by viral uveitis;
  • Recommended systemic/local antiviral drug use for ≥ 1 week
  • Continue use of antiviral drugs for more than 3 months post-op;
  • During systemic use of antiviral drugs, according to the type of drug used, routine blood tests and liver function tests, etc., should be conducted every month
  • Monitor possible side effects and adjust treatment options

2 Use of anti-infection medication – bacterial infection

  • According to the drug sensitivity test results, select the appropriate systemic/local anti-bacterial medication type;
  • If no drug sensitivity test results are available, select a broad-spectrum antibacterial drug;
  • Levofloxacin eye drops are usually used locally;
  • For patients with anterior chamber empyema, the anterior chamber can be flushed with diluted antibacterial drugs during operation;
  • Continue use of systemic/local antibacterial medication for 2 weeks or more post-op

3 Use of anti-infection medication – fungal infection

Before receipt of fungal strain identification results, treat according to experience:

  • Preferred choice: frequent use of 5% natamycin opththalmic solution or 0.1%-0.2% amphotericin B solution
  • For patients with suspected yeast infections, combine use of 0.5% fluconazole eye drops, gradually reducing the eye drops use as the condition improved

After obtaining the results of the drug sensitivity test, select appropriate drugs:

  • Usually select a synergistic combination of two drugs;
  • People with severe fungal infection (combined with endothelial plaques, hysterospyosis, suspicious endophthalmitis) can be given topical medications

4Use of anti-infection medication – amoebic infection

Commonly used drugs

  • 0.02 - 0.04 Chlorheixdine solution and 0.02 PHMB solution
  • Can be supplemented with fluconazole eye drops
  • Intravenous systemic injection or topical drops of metronidazole has anti-amoebic infection effects
  • Do not use glucocorticoids systemically or locally during infection
  • Local use of anti-amoebic drugs post-op, 4-6 times per day, course of treatment > 1 month
  • Post-op recurrence of amoebic infection usually occurs within a month. Recommended close follow-up for at least a month.

4. IOP is critical in the success of corneal transplantation

Close follow-up and referral is very important post-op

Effective follow-up post-op is important for good recovery

Holistic and timely information on the condition allows time for surgical intervention if needed

Both doctors and nurses should understand the importance of follow-up to late-stage recovery

The success of the operation is just a factor of the overall success, post-op care, drug use and follow-up is equally important

 (Noted: The dosage of the recommended medications above depends on the doctor’s preference and is adjustable according to the individualized conditions.)

 

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