Corneal Graft Rejection Treatment & Management

  • Author: Jason Jacobs, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 17, 2010
 

Medical Care

  • Treatment of graft rejection depends on the type of rejection; however, in all cases, topical corticosteroids are the mainstay of treatment. Epithelial or stromal rejection without endothelial involvement usually does not progress to graft failure. As previously noted, epithelial rejection may be a self-limited process. Nonetheless, epithelial and stromal rejection should be aggressively treated, because they indicate host immunologic recognition of the graft and may precede a more severe endothelial rejection. Topical corticosteroids (eg, dexamethasone 0.1%, prednisolone acetate 1%) are prescribed 4-6 times/d until the signs of rejection resolve, followed by a slow tapering of the topical medication. These patients should be followed closely to be certain that the signs of rejection are improving and that endothelial rejection has not developed.
  • In cases of endothelial rejection, treatment must be more aggressive if the episode is to be reversed. Topical corticosteroids should be used every hour while awake and as frequently as possible at night for 2-3 days, followed by every 2 hours while awake. Steroid ointment may be used at bedtime. Therapy should be continued until signs of rejection resolve. Topical medications should be tapered slowly over several weeks to a few months depending upon the patient's response to treatment. Therapy should be continued for at least 3 weeks in the absence of response before judging that the graft has failed.
  • Other routes of administration of corticosteroids can be used in more severe endothelial rejections, in recurrent rejections, or if the patient is at high risk (eg, alkali burns, patients with vascularized corneas). Corticosteroids may be given by subconjunctival injection (eg, dexamethasone phosphate 2 mg, betamethasone 3 mg in 0.5 mL). A less painful alternative is a collagen shield soaked in corticosteroids and applied to the cornea combined with frequent corticosteroid eye drops. The collagen shield results in a higher local concentration of steroid than can be obtained by the use of corticosteroid drops alone. The shield acts as a depot reservoir for the drug that slowly releases its contents during the period between topical applications. Higher steroid concentrations have been noted in the cornea, aqueous humor, iris, and vitreous, compared with hourly drops alone.
  • Systemic corticosteroids can also be used in cases of severe endothelial rejection. Oral prednisone is generally started at dosages of 60-80 mg daily and continued for as long as 1-2 weeks before tapering. In line with findings in other fields of medicine, data suggest that pulsed intravenous (IV) steroids may be more effective than oral prednisone in reversing corneal graft rejection. Pulsed steroids (a single IV administration of 500 mg methylprednisolone) have been shown to improve the percentage of graft survival compared with oral steroids in patients who present early (within the first 8 d) in a rejection episode. A nonsignificant trend toward improved survival in all episodes of rejection in favor of pulsed steroids exists. In addition, pulsed steroids reduce the risk of subsequent rejection episodes, which may be a significant benefit in higher risk corneal grafts. Pulsed steroids also avoid prolonged administration of oral steroids.
  • In all cases of rejection, intraocular pressure should be monitored closely, especially when frequent corticosteroids are used. If necessary, elevated intraocular pressure should be controlled by topical medications to prevent glaucoma and to improve the chance of graft survival.
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Surgical Care

  • No surgical care has proven beneficial during an episode of acute graft rejection.
  • Some transplant surgeons scrape the donor corneal epithelium to reduce the antigen load.
  • No solid evidence suggests that removing the donor epithelium is beneficial in reducing the risk of subsequent graft rejection.
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Diet

  • No dietary restrictions have been identified.
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Activity

  • No activity restrictions have been noted.
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Contributor Information and Disclosures
Author

Jason Jacobs, MD  Clinical Faculty, Department of Ophthalmology, University of Colorado Health Sciences Center

Jason Jacobs, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, International Society of Refractive Surgery, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Taravella, MD  Director of Cornea and Refractive Surgery, Rocky Mountain Lions Eye Institute; Professor, Department of Ophthalmology, University of Colorado School of Medicine

Michael Taravella, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, and Eye Bank Association of America

Disclosure: Alcon Honoraria Speaking and teaching; Allergan Honoraria Speaking and teaching; Surgical Specialties Honoraria Speaking and teaching; BD Surgical Supplies Honoraria Speaking and teaching

Specialty Editor Board

Jack L Wilson, PhD  Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee at Memphis

Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Lee HS, Kim MS. Influential factors on the survival of endothelial cells after penetrating keratoplasty. Eur J Ophthalmol. Nov-Dec 2009;19(6):930-5. [Medline].

  2. Bertelmann E, Pleyer U. Immunomodulatory therapy in ophthalmology - is there a place for topical application?. Ophthalmologica. Nov-Dec 2004;218(6):359-67. [Medline].

  3. Sloper CM, Powell RJ, Dua HS. Tacrolimus (FK506) in the management of high-risk corneal and limbal grafts. Ophthalmology. Oct 2001;108(10):1838-44. [Medline].

  4. Boisjoly HM, Tourigny R, Bazin R, Laughrea PA, Dube I, Chamberland G, et al. Risk factors of corneal graft failure. Ophthalmology. Nov 1993;100(11):1728-35. [Medline].

  5. Chen YF, Gebhardt BM, Reidy JJ, Kaufman HE. Cyclosporine-containing collagen shields suppress corneal allograft rejection. Am J Ophthalmol. Feb 15 1990;109(2):132-7. [Medline].

  6. Hegde S, Beauregard C, Mayhew E. CD4(+) T-cell-mediated mechanisms of corneal allograft rejection: role of Fas-induced apoptosis. Transplantation. Jan 15 2005;79(1):23-31. [Medline].

  7. Hill JC. Systemic cyclosporine in high-risk keratoplasty. Short- versus long-term therapy. Ophthalmology. Jan 1994;101(1):128-33. [Medline].

  8. Hill JC. The use of cyclosporine in high-risk keratoplasty. Am J Ophthalmol. May 15 1989;107(5):506-10. [Medline].

  9. Hill JC, Maske R, Watson P. Corticosteroids in corneal graft rejection. Oral versus single pulse therapy. Ophthalmology. Mar 1991;98(3):329-33. [Medline].

  10. Hwang DG, Stern WH, Hwang PH, MacGowan-Smith LA. Collagen shield enhancement of topical dexamethasone penetration. Arch Ophthalmol. Sep 1989;107(9):1375-80. [Medline].

  11. Khodadoust AA, Silverstein AM. Transplantation and rejection of individual layers of the cornea. In: Investigative Ophthalmologic and Visual Sciences. Vol 8. 180-195.

  12. Reidy JJ, Gebhardt BM, Kaufman HE. The collagen shield. A new vehicle for delivery of cyclosporin A to the eye. Cornea. Jul 1990;9(3):196-9. [Medline].

  13. Smolin G, Thoft RA. The cornea. In: Scientific Foundations and Clinical Practice. 3rd ed. Lippincott William & Wilkins; 1994.

  14. Wang M, Lin Y, Chen J, Liu Y, Xie H, Ye C. Studies on the effects of the immunosuppressant FK-506 on the high-risk corneal graft rejection. Yan Ke Xue Bao. Sep 2002;18(3):160-4. [Medline].

  15. Wilson SE, Kaufman HE. Graft failure after penetrating keratoplasty. Surv Ophthalmol. Mar-Apr 1990;34(5):325-56. [Medline].

 
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This severely vascularized cornea would be at high risk for graft rejection following a penetrating keratoplasty. This patient experienced Stevens-Johnson syndrome.
This is an example of an acute graft rejection episode. Note the graft edema, Descemet folds, and keratic precipitates.
 
 
 
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