Corticosteroids needed after DALK to avert stromal rejection

By Sarah Guy, medwireNews Reporter

Like those undergoing penetrating keratoplasty, patients treated with deep anterior lamellar keratoplasty (DALK) may benefit from taking postoperative corticosteroids to prevent stromal rejection, report US researchers.

A quarter of the DALK patients followed up in their study developed stromal rejection, suggesting a clinically significant incidence rate of the complication, say the researchers.

"If left untreated or undiagnosed, these patients can have persistent signs and symptoms that may jeopardize visual outcomes because permanent stromal scarring may lead to profound visual loss," remark Surendra Basti (Northwestern University, Chicago, Illinois) and colleagues.

Characterizing stromal rejection could aid in prevention and early diagnosis, they add, in Cornea.

Of 20 patients treated with DALK between October 2006 and January 2008, five experienced an episode of stromal rejection, after a mean 6.3 months. The majority of patients presented with pain, photophobia, and redness, with some experiencing blurry vision and a foreign body sensation.

The researchers report that the four cases of rejection among the five were treated aggressively, with q1-3 hourly prednisolone acetate 1% eye drops tapered off over 2-4 weeks.

The remaining patient with stromal rejection was treated with an initial maximal dose of only prednisolone acetate 1%, four times per day, as it was seen as a more moderate rejection. However, after less than 5 months, the individual experienced a second 2-week rejection episode.

All patients' symptoms and signs were reversed after treatment; however, the researchers note that two of the five individuals had been receiving low-dose corticosteroid eye drops when they were diagnosed with rejection.

"This illustrates that low-dose corticosteroid therapy alone may not be adequate to prevent the occurrence of stromal rejection," they write, adding that although the study was underpowered to test its long-term use "it may be prudent to maintain patients on topical corticosteroids... at least daily for the first 12 months postoperatively and possibly beyond."

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