Stromal rejection following deep anterior lamellar keratoplasty: implications for postoperative care.

To better characterize stromal rejection in the context of deep anterior lamellar keratoplasty (DALK) to improve early diagnosis and proper management. The clinical records of 22 patients undergoing DALK by 2 surgeons between October 2006 and January 2008 were reviewed to identify patients who experienced stromal rejection. The diagnosis was made after the demonstration of acute stromal edema and/or stromal neovascularization in the absence of confounding preoperative conditions, such as herpetic keratitis. The incidence and clinical features of stromal rejection were compared with other descriptions found in the literature. Five of 20 eligible patients experienced stromal rejection within 12 months. Two patients were on low-dose corticosteroids when diagnosed. Four of the 5 patients were treated aggressively with q1-3 hourly prednisolone acetate 1% eye drops. The fifth was treated less aggressively with a maximum dose of only q6 hourly prednisolone acetate 1% and subsequently experienced a second rejection episode less than 5 months later. All episodes resolved completely with treatment. The incidence of stromal rejection in DALK is clinically significant, suggesting that these patients may benefit from corticosteroid regimens similar to those used in penetrating keratoplasty and implies that stromal rejection may be more common in penetrating keratoplasty than previously reported. If misdiagnosed or left untreated, stromal rejection can compromise graft clarity but prompt recognition and aggressive treatment can result in good anatomic and visual outcomes.