SYSTEMIC CYCLOSPORINE-A IN HIGH-RISK KERATOPLASTIES

Background: It was the purpose of this study to compile the results of all high-risk keratoplasties (kp) performed in our hospital under sys temic ciclosporin A (Ci A) cover from 1987 through 1994. Methods: One hundred and thirty-one keratoplasties were performed. Ci A was adminis tered for an average period of 9.4 months. We aimed at trough levels o f 100-150 ng/ml (monoclonal RIA/TDx). The 29 kp in group A were second or third repeat kp and/or the recipient cornea had severe deep vascul arization in all quadrants and/or a transplant position at the limbus was inevitable (expected risk: only immune reactions). The 40 kp in gr oup B were threatened by severe ocular surface disorders (without seve re limbal stem cell insufficiency) and by immune reactions (atopic ker atopathy, keratoconus with severe endogenous eczema or chronic blephar okeratoconjunctivitis). In the 45 kp of group C resurfacing problems f rom severe limbal stem cell insufficiency and immune reactions were an ticipated (severe burns, pseudopemphigoid or Lyell syndrome). Group D comprised 17 kp with various diagnoses (e.g. kp in newborns, rheumatic and Acanthamoeba keratitis). Results: In group A 91% of the grafts we re clear 2 years postoperatively, in group B 76%, in group C 38% and i n group D 18%. In 32 of 41 failed grafts (78%), resurfacing problems w ere the only reason for or participated in final graft failure. Immune reactions and other causes of graft failure were of minor importance. Conclusions: (1) Systemic Ci A cover can efficiently suppress immune reactions. (2) With the suppression of immune reactions, resurfacing d isorders become the most important single cause for functional graft f ailure. (3) For eyes with a considerable loss of limbal stem cells, li mbal stem cell transplantation should be combined with systemic Ci A c over in order to improve the long-term prognosis for penetrating kerat oplasty.