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Sang Yoon Lee 1,2 , Sang- Mok Lee 1,3 , Won Ryang Wee 1,2 ,

Late-onset Stromal Graft Rejection Triggered by Viral Conjunctivitis after Deep lamellar keratoplasty in Keratoconus. Sang Yoon Lee 1,2 , Sang- Mok Lee 1,3 , Won Ryang Wee 1,2 , Jin- Hak Lee 1,2 , Mee Kum Kim 1,2

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Sang Yoon Lee 1,2 , Sang- Mok Lee 1,3 , Won Ryang Wee 1,2 ,

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  1. Late-onset Stromal Graft Rejection Triggered by Viral Conjunctivitis after Deep lamellar keratoplasty in Keratoconus Sang Yoon Lee1,2, Sang-Mok Lee1,3, Won Ryang Wee1,2, Jin-Hak Lee1,2, MeeKum Kim1,2 Seoul Artificial Eye Center, Seoul National University Hospital Clinical Research Institute 1 Department of Ophthalmology, Seoul National University College of Medicine2 The armed forces capital hospital, Seoul National University College of Medicine3 The authors have no financial interest

  2. Introduction • Deep anterior lamellar keratoplasty (DALK) • Placing a donor corneal graft within a recipient corneal bed that is prepared with removal of all recipient stromal tissue to Descemet’s membrane • For patients with corneal stromal disease and normal endothelium like keratoconus • Rejection in PKP & DALK • Endothelial rejection occurs in 20% to 30% of patients in PKP • Most graft rejections occur in the first 3 years after keratoplasty • Most frequently over the first 12 months • No endothelial rejection in DALK • Stromal rejection after DALK

  3. Case (M/18) B) Keratoconus • VA (0.5/FC) • Cornea B) bowing, central thinning

  4. L) Deep anterior lamellar keratoplasty done Postop5 months • Vos 0.7, Tos 15 • Cornea : 10o/c new vessel appeared after broken suture developed, but NV regressed after broken suture removed • Ocumetholoneq.i.d, 0.5% cyclosporine b.i.d.

  5. Viral Conjunctivitis episode Postop21 months • Vos (0.6), Tos 18 • Graft : clear • Medication : 0.05% cyclosporine b.i.d. Postop23 months • B) Epidemic keratoconjunctivitis occurred for 2 weeks • Graft : clear • Medication : levofloxacinq.i.d., flumetholoneq.i.d. for 2 weeks Postop 23.5 months • Vos (0.4) • Conjunctiva L) follicular hypertrophy (-), injection (-) • Graft : clear

  6. Later Rejection developed Diffuse stromal infiltration Endothelial edema Previous NV d/t broken suture Postop24 months • C.C. acute visual loss (onset : 2 days ago) • Vos (0.02) • Assessment : L acute rejection • Medication and Treatment • Predforteq1hour • Prednisolone60mg poqd Conjunctival injection

  7. Rejection - regressing Post-rejection 1 week Vos (0.15), Tos11

  8. Rejection - remission Edema, stromal infiltration clear up Subepithelial opacity remained • Post-rejection 11 weeks, Post-PKP 27 months • Vos (0.4), Tos 16-17 • Medication • 0.5% cyclosporine q.d. • Ocumetholoneq.i.d. • He is a steroid responder. That is why we did not use high potency of steroid

  9. Summary New vessel develop and regressed (postop. 5 mo) Steroid treatment Viral conjunctivitis (postop. 23mo) DALK Acute rejection (postop 24mo) Remission (postop 27mo)

  10. Discussion • Rejection in PKP & DALK • A few reports about stromal rejection in DALK • 0%~8% of patients • 16 months~24 months after DALK • Rejection & ocular inflammation • Ocular inflammation is known as a risk factor of rejection in PKP. • Previous report • Herpes keratitis • Allergic conjunctivitis • Atopic dermatitis • Allergic airway hyperreactivitiy • No previous report about viral conjunctivitis

  11. Conclusion • Acute stromal allograft rejection can occur 24 months after DALK. • Viral conjunctivitis seems to be able to trigger stromal graft rejection in DALK, which is known to have less tendency of rejection.

  12. Reference • Flynn, Obbayashi, et al. Effect of allergic conjunctival inflammation on the allogeneic response to donor cornea. Invest Ophthalmol Vis Sci 48(9): 4044-9 • Al-Torbak, Malak, et al. Presumed stromal graft rejection after deep anterior lamellar keratoplasty. Cornea 24(2): 241-3 • Wagoner, Ba-Abbad, et al. Postoperative complications after primary adult optical penetrating keratoplasty: prevalence and impact on the graft survival. Cornea 28(4): 385-94 • Noble, Agrawal, et al. Deep anterior lamellar keratoplasty (DALK): visual outcome and complications for a heterogeneous group of corneal pathologies. Cornea 26(1): 59-64

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