Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Deutschland.
Klin Monbl Augenheilkd. 2022 Jun;239(6):775-785. doi: 10.1055/a-1774-4862. Epub 2022 Apr 29.
Corneal transplantation is the most commonly performed human tissue transplantation procedure worldwide. Due to the large number of grafts, corneal graft failure has become one of the most common indications for corneal transplantation for immunological and non-immunological reasons (e.g. recurrence of underlying disease, high intraocular pressure, grafted guttae, transmitted HSV or CMV infection). The relatively recently developed lamellar grafting techniques have introduced certain potential complications that may lead to graft failure and require approaches other than penetrating keratoplasty for re-grafting. On the other hand, these new lamellar techniques also offer new possibilities for salvaging failed penetrating grafts, with potential advantages over successive penetrating keratoplasties, such as lower intraoperative risks, faster visual rehabilitation and reduced risk of immune reaction. Today, the patient with good healing who is satisfied with his graft before endothelial decompensation, with low astigmatism and no stromal scars, represents the optimal condition for DMEK after PKP. This can also be combined with phacoemulsification (so-called triple DMEK). Otherwise, a penetrating re-keratoplasty with a larger graft (typically excimer laser repeat PKP 8.5/8.6 mm) is performed to treat edema, scars and irregular astigmatism simultaneously. The medical history carries weight in this decision! Re-DMEK in case of graft failure after DMEK and DSAEK does not require any modification of the standard technique and leads to good visual acuity results if performed quickly. If there is clear stromal scarring after multiple (external) DMEKs, PKP can also be considered to rectify the situation. Otherwise causeless recurrent graft failures must suggest herpetic or CMV endotheliitis and, after PCR analysis of the aqueous humour aspirate, be treated appropriately with medication.
角膜移植是全球最常见的人体组织移植手术。由于供体数量众多，免疫和非免疫原因导致的角膜移植失败已成为最常见的角膜移植适应证之一（例如，基础疾病复发、眼内压升高、移植片水肿、单纯疱疹病毒或巨细胞病毒感染）。最近开发的板层移植技术带来了一些潜在的并发症，可能导致移植失败，需要采用穿透性角膜移植术以外的方法进行再次移植。另一方面，这些新的板层技术也为挽救穿透性移植失败提供了新的可能性，与连续穿透性角膜移植术相比具有潜在优势，例如术中风险较低、视力恢复较快以及免疫反应风险降低。如今，在没有内皮失代偿、散光低且基质无瘢痕的情况下，愈合良好且对移植物满意的患者是行穿透性角膜移植术后行 DMEK 的最佳条件。这也可以与白内障超声乳化术（所谓的三联 DMEK）相结合。否则，需要进行穿透性再移植，采用更大的移植物（通常为准分子激光重复穿透性角膜移植术 8.5/8.6mm），同时治疗水肿、瘢痕和不规则散光。病史在这一决策中具有重要意义！如果在 DMEK 和 DSAEK 后发生移植物失败，再次行 DMEK 不需要对标准技术进行任何修改，如果能及时进行，可获得良好的视力结果。如果在多次（外部）DMEK 后出现明显的基质瘢痕，可以考虑行穿透性角膜移植术来矫正病情。否则，无端发生的复发性移植物失败必须提示疱疹或巨细胞病毒内皮炎，在对房水抽吸物进行聚合酶链反应分析后，应适当用药进行治疗。
