这项研究的目的是回顾已发表的发病率,病因学,板层角膜移植术后发生感染性界面角膜炎(IIK)患者的临床特征和治疗。
本研究为系统文献综述。
我们通过PubMed搜索,使用以下术语对已发表的中文和英文报告进行了系统回顾:角膜移植,角膜移植术,前板层角膜移植术(ALK),深前板层角膜移植术(DALK),深板层内皮角膜移植术(DLEK),Descemet膜内皮角膜移植术(DMEK),Descemet剥离内皮角膜移植术(DSEK),Descemet剥离自动内皮角膜移植术(DSAEK),感染性界面角膜炎(IIK),真菌性角膜炎,和细菌性角膜炎。收集的数据包括患者人口统计学,外科技术,临床体征,治疗,结果,和捐赠者的边缘文化。还对相关文献进行了回顾。
从2007年到2月2018年,我们确定了板层角膜手术后IIK的62例。DALK/ALK组平均年龄26.95±8.80岁,男女比例11:8,DSAEK/DSEK/DMEK组平均年龄69.65±8.00岁,男女比例17:16(10例无性别信息)。在62个案例中,46例(75.41%)为真菌,9例(14.75%)为细菌性,放线菌属2例(3.28%),1例(1.64%)为棘阿米巴,不确定者4例(6.56%)。DALK/ALK组患者症状平均发病天数(POD)49.47±48.56,EK组53±112.01,细菌性角膜炎为62.44±50.07,真菌性角膜炎为51.5±102.42。术后随访时间DALK/ALK组平均10.10±9.36个月,DSAEK/DSEK/DMEK组平均12.37±12.28个月。在总共62个案例中,1例(1.61%)肺炎克雷伯菌阳性供体边缘培养物与IIK中的相同病原体有关,在IIK中,有16例(25.81%)的真菌阳性供体边缘培养物与相同的病原体相关。临床症状包括结膜注射,接口不透明度,细菌性角膜炎的基质水肿,在某些真菌性角膜炎的病例中,在与内皮斑块的界面处有密集的白色浸润。药物治疗包括局部和口服抗微生物剂。手术干预包括治疗性角膜移植术。15例(24.19%),医疗管理是成功的。在剩下的47个案例中,8例(12.90%)接受了重复的板层角膜移植术(LK),39例(62.90%)对保守药物治疗无反应,并接受了治疗性角膜移植术(TKP)。感染后最佳矫正视力(BCVA)为7眼logMAR0(11.29%),20只眼睛中大于或等于logMAR0.4(32.26%),22只眼小于logMAR0.4(35.48%),13只眼小于logMAR0.7(20.97%)。在边缘培养阴性组(n=19)中,平均BCVA为logMAR0.59±0.68,边缘培养阳性组为logMAR0.44±0.74(n=15)。在术后随访期间,有3例DMEK术后复发。
感染性界面角膜炎(IIK)是板层角膜移植术的罕见并发症,但它可能会导致视力严重丧失或永久性失明。虽然移植物感染可在手术后的任何时间发生,最常见(87%)发生在术后前3个月(54/62例)。板层角膜移植术后最常见的IIK致病生物是白色念珠菌。阳性边缘培养结果可以提供针对所鉴定的生物体的更快速和适当的治疗。治疗性角膜移植术(TKP)是治疗IIK的最常见外科手术。TKP后的视觉结果是公平的,32.26%(20/62)的患者获得LogMAR0.4或更高。
The purpose of this study was to review the published incidence, etiology, clinical features and management of patients who developed infectious interface keratitis (IIK) following lamellar keratoplasty.
This study is a systematic literature review.
We conducted a systematic review of published Chinese and English report through a PubMed search with the medical subject headings using the following terms: corneal transplantation, keratoplasty, anterior lamellar keratoplasty (ALK), deep anterior lamellar keratoplasty (DALK), deep lamellar endothelial keratoplasty (DLEK), Descemet membrane endothelial keratoplasty (DMEK), Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (
DSAEK), infectious interface keratitis (IIK), fungal keratitis, and bacterial keratitis. Data collected included patient demographics, surgical technique, clinical signs, treatment, outcomes, and donor rim cultures. A review of the relevant literatures was also undertaken.
From 2007 to Feb. 2018, we identified 62 cases of IIK following lamellar corneal surgery. The mean age was 26.95 ± 8.80 years with a male/female ratio of 11:8 in DALK/ALK group and 69.65 ± 8.00 years with a male/female ratio of 17:16 in
DSAEK/DSEK/DMEK group (no gender information for 10 cases). Of the 62 cases, 46 cases (75.41%) were fungal, 9 cases (14.75%) were bacterial, 2 cases (3.28%) were Actinomyces species, 1 case (1.64%) was acanthamoeba, and 4 cases (6.56%) were indeterminant. The mean onset of symptoms was postoperative day (POD) 49.47 ± 48.56 in DALK/ALK group, and 53 ± 112.01 in EK group, and 62.44 ± 50.07 for the bacterial keratitis, and 51.5 ± 102.42 for fungal keratitis. The mean postoperative follow-up period was 10.10 ± 9.36 months in DALK/ALK group and 12.37 ± 12.28 months in
DSAEK/DSEK/DMEK group. Of the total 62 cases, 1 case (1.61%) with a Klebsiella pneumoniae positive donor rim cultures was associated with the same pathogen in the IIK, and 16 cases (25.81%) of fungal positive donor rim cultures were associated with the same pathogen in the IIK. Clinical signs included conjunctival injection, interface opacity, stromal edema for bacterial keratitis, and dense white infiltrates at the interface with endothelial plaques in some cases of fungal keratitis. Medical treatment included topical and oral antimicrobial agents. Surgical interventions included therapeutic keratoplasty. In 15 cases (24.19%), medical management was successful. Of the remaining 47 cases, 8 (12.90%) were managed with a repeat lamellar keratoplasty (LK) and 39 (62.90%) were unresponsive to conservative medical treatment and underwent a therapeutic keratoplasty (TKP). Post infectious best corrected visual acuity (BCVA) was logMAR 0 in 7 eyes (11.29%), better than or equal to logMAR 0.4 in 20 eyes (32.26%), less than logMAR 0.4 in 22 eyes (35.48%) and logMAR 0.7 or worse in 13 eyes (20.97%). In the rim culture negative group(n = 19), the average BCVA was logMAR 0.59 ± 0.68, with was logMAR 0.44 ± 0.74 in rim culture positive group (n = 15). There were three recurrence cases were reported after DMEK during the postoperative follow-up period.
Infectious interface keratitis (IIK) is an uncommon complication of lamellar keratoplasty, but it can result in a substantial loss of vision or permanent blindness. Although graft infection can occur at any time following surgery, it most commonly (87%) occurred during the first 3 months postoperatively (54/62 cases). The most commonly reported causative organism of IIK following lamellar keratoplasty was C. albicans. Positive rim culture results can provide more rapid and appropriate treatment directed to the identified organism. Therapeutic keratoplasty (TKP) was the most common surgical procedure for the management of IIK. Visual outcomes post TKP are fair with 32.26% (20/62) of patients obtaining LogMAR 0.4 or better.