Late stromal rejection in DALK
Reviewed by Magdalena Popiela

This case series reported on late stromal rejections in eyes after uncomplicated deep anterior lamellar keratoplasties (DALKs). Four eyes of three patients experienced episodes of isolated stromal rejection 33 to 46 months after surgically uncomplicated DALKs and a minimum of 19 months after suture removal. Indications for DALKs were keratoconus in three eyes and infective keratitis in one eye. All patients presented with symptoms of ocular irritation and redness with reduction in vision in three patients. Examination revealed superficial vascularisation in all eyes and deep neovascularisation in two eyes. The stroma of the donor cornea next to vascularisation was oedematous and opaque in all cases. Anterior chamber activity was minimal. All patients were treated with intensive topical corticosteroids with resolution of rejection and restoration of pre-rejection best spectacle corrected visual acuity with up to 18 months follow-up. Tapering dose of steroids was continued for eight to 12 months. In one eye topical steroids were reintroduced at 13 months because of a further rejection episode. The best spectacle-corrected distance acuity was >=20/30 in all eyes at the last follow-up visit. Current evidence of what happens to donor keratocytes following DALKs is conflicting, this case series supports the evidence that donor keratocytes may persist in DALKs indefinitely, and can contribute to the late stromal rejection. Patients need to be educated to seek ophthalmic help if they develop red irritated eye even years after treatment.

Late stromal rejection in deep anterior lamellar keratoplasty: a case series.
Roberts H, Maycock N, O’Brart D.
CORNEA
2016;35(9):1179-81.