Department of Ophthalmology, University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.
Department of Ophthalmology, University of Cologne, Cologne, Germany.
Prog Retin Eye Res. 2019 Nov;73:100768. doi: 10.1016/j.preteyeres.2019.07.001. Epub 2019 Jul 3.
In the past decade, novel lamellar keratoplasty techniques such as Deep Anterior Lamellar Keratoplasty (DALK) for anterior keratoplasty and Descemet stripping automated endothelial keratoplasty (DSAEK)/Descemet membrane endothelial keratoplasty (DMEK) for posterior keratoplasty have been developed. DALK eliminates the possibility of endothelial allograft rejection, which is the main reason for graft failure after penetrating keratoplasty (PK). Compared to PK, the risk of endothelial graft rejection is significantly reduced after DSAEK/DMEK. Thus, with modern lamellar techniques, the clinical problem of endothelial graft rejection seems to be nearly solved in the low-risk situation. However, even with lamellar grafts there are epithelial, subepithelial and stromal immune reactions in DALK and endothelial immune reactions in DSAEK/DMEK, and not all keratoplasties can be performed in a lamellar fashion. Therefore, endothelial graft rejection in PK is still highly relevant, especially in the "high-risk" setting, where the cornea's (lymph)angiogenic and immune privilege is lost due to severe inflammation and pathological neovascularization. For these eyes, currently available treatment options are still unsatisfactory. In this review, we will describe currently used keratoplasty techniques, namely PK, DALK, DSAEK, and DMEK. We will summarize their indications, provide surgical descriptions, and comment on their complications and outcomes. Furthermore, we will give an overview on corneal transplant immunology. A specific focus will be placed on endothelial graft rejection and we will report on its incidence, clinical presentation, and current/future treatment and prevention options. Finally, we will speculate how the field of keratoplasty and prevention of corneal allograft rejection will develop in the future.
在过去的十年中，已经开发出了新型的层状角膜移植技术，例如用于前层角膜移植的深层前层角膜切开术（DALK）和用于后层角膜移植的 Descemet 剥离自动化内皮角膜移植术（DSAEK）/Descemet 膜内皮角膜移植术（DMEK）。DALK 消除了内皮同种异体移植物排斥的可能性，这是穿透性角膜移植（PK）后移植物失败的主要原因。与 PK 相比，DSAEK/DMEK 后内皮移植物排斥的风险显著降低。因此，在现代层状技术下，内皮移植物排斥的临床问题在低风险情况下似乎已基本解决。但是，即使进行层状移植，在 DALK 中仍会发生上皮、上皮下和基质免疫反应，在 DSAEK/DMEK 中会发生内皮免疫反应，并非所有的角膜移植都可以以层状方式进行。因此，PK 中的内皮移植物排斥仍然高度相关，尤其是在“高风险”情况下，由于严重的炎症和病理性新生血管化，角膜（淋巴）血管生成和免疫特权丧失。对于这些眼睛，目前可用的治疗选择仍不理想。在这篇综述中，我们将描述目前使用的角膜移植技术，即 PK、DALK、DSAEK 和 DMEK。我们将总结其适应证，提供手术描述，并对其并发症和结果进行评论。此外，我们将概述角膜移植免疫。将特别关注内皮移植物排斥，并报告其发生率，临床表现以及当前/未来的治疗和预防选择。最后，我们将推测角膜移植和预防角膜同种异体移植物排斥领域将来如何发展。
