Patterns of rejection after deep lamellar keratoplasty

Purpose: To describe 7 patients with keratoconus who underwent graft rejection after deep lamellar keratoplasty (DLK). Design: Retrospective case series and literature review. Participants: Seven patients who underwent DLK for keratoconus between 1997 and 2001. These cases were compared with a previously reported case series of DLK for keratoconus between 1994 and 2001. Methods: The clinical records of patients with rejection after DLK for keratoconus were examined to obtain details of the surgery, the interval to the rejection episode and its treatment, best-corrected visual acuity (BCVA), and presence of potential risk factors for rejection. The clinical features and course of rejection were compared with reports of corneal graft rejection in the literature. Patient characteristics were compared with the reported series of patients who had DLK for keratoconus. Main Outcome Measures: Final BCVA and number, type, and features of rejection episodes. Results: The mean age was 28 years, with a median follow-up of 40 months after DLK Rejection occurred between 3 and 41 months postoperatively. Four patients were atopic, 4 had a penetrating keratoplasty in the fellow eye, and 1 had deep stromal vessels in the host cornea. Isolated epithelial rejection occurred in 1 patient and stromal rejection in 3 cases, and there were 3 cases of mixed stromal and epithelial rejection. Topical steroid therapy led to reversal of rejection in 5 cases. Two patients had progressive vascularization with graft failure and poor vision. The median final BCVA was 6/9 (range, 6/6-6/36). Conclusions: Deep lamellar keratoplasty avoids the risk of endothelial rejection, but epithelial or stromal rejection may still occur. Recognition and appropriate treatment are needed to prevent graft failure with subsequent visual loss.