Evaluation of Corneas From Donors With Septicemia for Use in Corneal Transplant

To the Editor: We read with interest the recent article published by Ma et al.1 In their series of dehisced penetrating keratoplasty (PKP) grafts, 76% of eyes lost their artificial or natural lenses during trauma, and the authors noted that although not statistically significant, there was a trend toward improved visual outcomes in patients with retention of their lens. This agrees with previous reports that lens extrusion during traumatic wound dehiscence is associated with a poor visual outcome.2–5 In the study by Kawashima, eyes in which lens damage occurred were associated with a significantly decreased final best-corrected visual acuity than those without lens damage (P , 0.001), with some cases even requiring primary evisceration.2 Although we agree that lens damage portends a poorer prognosis, the presence of vitreous loss carries even more prognostic significance. Vitreous loss substantially increases the risk of posterior segment complications such as macular edema and retinal detachment. Illustrating this point is a recent case treated at our institution of a 42year-old man with a history of keratoconus who sustained traumatic crystalline lens expulsion and wound dehiscence of 6 clock hours of his PKP graft. No vitreous was encountered during wound repair and postoperatively, slit-lamp examination revealed an intact anterior hyaloid face. Three months after his injury, his corrected acuity was 20/25 with an aphakic contact lens. Wound dehiscence of a PKP graft requires considerable traumatic force, perhaps even more so to result in lens expulsion and vitreous loss. However, considering lens status as a proxy for the magnitude of traumatic force and prognosticator of visual outcomes can be misleading, as numerous factors influence whether vitreous loss accompanies lens expulsion. Zonulopathies such as pseudoexfoliation, Marfan syndrome, or even previous trauma present scenarios in which clean intracapsular cataract extraction can occur with relatively little trauma and without vitreous loss. In addition, formed vitreous, present in young patients such as our case, provides more resistance to rupture of the anterior hyaloid face. These factors may in fact be protective against vitreous loss, thus conferring a better visual prognosis in these traumatic cases.