What should be paid attention to in corneal leukoplakia and corneal transplantation in infants?

The inspiration of this article comes from the questions raised by the readers of xiaohongshu. Her child was diagnosed with congenital corneal leukoplakia seven days after birth. She wanted to know whether the child could use the Mich artificial cornea.

I looked at the photos of the child. It was lovely, but the corneal white spot caused the child to look less energetic. I really want to help him, but it's a pity that the child is too young to use the Michal artificial cornea.

Readers who are familiar with us know that we have been carrying out popular science on adult corneal transplantation / artificial corneal transplantation for a long time, but children's corneal transplantation / artificial corneal transplantation has not been involved. There are many reasons for this. But now that someone has asked, I would like to take this opportunity to introduce some knowledge of corneal transplantation in the treatment of infant corneal leukoplakia.

It is estimated that 20% of the 1.4 million blind children in the world are caused by corneal diseases.

In the past, it was considered that penetrating keratoplasty in children, especially infants, was "taboo", mainly because of the high rate of rejection after keratoplasty.

However, because the central nervous system of children, especially the visual cortex of the visual path, is in the development stage, the retina of children with corneal opacity is not stimulated by enough light at the early stage after birth, which will lead to irreversible amblyopia and even visual loss.

Fortunately, with the progress of microsurgery technology and the application of new immunosuppressants, the survival rate of corneal grafts has been significantly improved.

Therefore, in recent years, many ophthalmologists have suggested that penetrating keratoplasty should be taken immediately in case of corneal leukoplakia in children, so that the retina of children can receive light or image stimulation as soon as possible to promote the development and formation of vision, reduce the degree of amblyopia and reduce the occurrence of corneal blindness.

However, advocating surgery does not mean that there is no risk.

Due to the different anatomical characteristics of children's eyeballs (mentioned below), compared with adult surgery, children's corneal transplantation is a higher risk and more complicated surgical process, and is a very challenging operation,

Therefore, not only doctors, but also parents should weigh whether corneal transplantation is worth doing? When did you do it? How to improve the success rate? I have consulted relevant literature and found some important information, which I will share with you here.

The first aspect to be shared is "when is better to have an operation". In fact, there are certain differences in the time of operation according to different etiologies and children's ages.

1、 Congenital corneal leukoplakia: once found, operate as soon as possible

① Some experts retrospectively analyzed 58 cases of congenital corneal leukoplakia, and considered that the best operation time was within a few weeks after birth.

Of course, considering that the cornea is relatively thin when the child is born, and the donor cornea provided by the general eye bank is adult cornea, the operation time can also be appropriately delayed.

② Some scholars suggest that corneal transplantation at 3 months after birth is the best. Because children's visual development is most sensitive within 4 months after birth, missing this time is not conducive to visual development.

2、 Acquired corneal leukoplakia: there are many factors to consider.

① If corneal leukoplakia occurs at or before the age of 5 years and affects visual development, penetrating keratoplasty should be performed in time after the active lesion is stable;

② If corneal leukoplakia occurs at the age of 8 years or later, elective surgery can be performed.

The second aspect I want to share is that the factors that affect the success rate of surgery are mainly judged by doctors. Parents can also have a rough look and have a good idea.

Generally, the eyes of infants and young children have the following characteristics:

① The sclera has low rigidity and strong elasticity, which leads to the displacement of the lens iris septum;

② Small eyeball and high intraoperative vitreous pressure increase the risk of lens dislocation;

③ Congenital corneal leukoplakia may be accompanied by other ocular diseases, such as iris adhesion, glaucoma, microphthalmia, etc;

④ The corneal and scleral trauma in infants has a large inflammatory reaction, and the rejection reaction is more rapid. The effect of drug treatment is not good.

The above four items are not so much characteristics as "risk sources", because they will lead to various complications.

If we talk about the complications of corneal transplantation, we must mention "immune rejection".

As we all know, immune rejection is the main reason that affects the survival of corneal grafts, both for adults and children. The active immune system in children even increases the possibility of immune rejection. More importantly, the effect of immunosuppressive treatment after corneal transplantation in children is significantly lower than that in adults.

For the prevention of corneal transplant rejection, the key is early detection. Meanwhile, parents should follow the doctor's advice to regularly apply medicine to their children, and pay special attention to the children's mood during this period.

It affects the success and survival of corneal grafts, and glaucoma is also "unavoidable".

As mentioned above, children's sclera has low rigidity and strong elasticity, and the lens iris septum is easy to move forward and dislocation, which will lead to secondary glaucoma in children early after penetrating keratoplasty; In addition, the anterior chamber reaction was large, and fibrous exudation induced anterior synechia around the iris; The presence of abnormal anterior chamber angle structure before operation is also a high-risk factor.

In addition, wound infection and corneal graft dissolution after keratoplasty in children also affect the survival of corneal grafts. Therefore, in this process, parents should listen to their children's feelings, pay attention to their emotions, follow the doctor's advice and cooperate with observation, and regularly use antibiotic eye drops.

As for the survival rate of children's corneal grafts, there are few domestic literature reports. Recent studies show that the total transparency rate of children's corneal grafts after keratoplasty has reached 71.4%, and the results are satisfactory.

Nowadays, more and more children with corneal blindness are seeing a bright future after penetrating keratoplasty in children, which is gratifying. However, how to improve the success rate of corneal leukoplakia in infants, especially congenital corneal leukoplakia, is still the research focus of ophthalmologists. At the same time, parents should pay close attention to their children's eye health. Some corneal opacity is hereditary, and special attention should be paid to family history and parents' physical examination.