Persistent epithelial defects and ulcers in repeated corneal transplantation: Incidence, causative agents, predisposing factors and treatment outcomes

Purpose: To evaluate the occurrence, predisposing factors and outcome of persistent epithelial defects and ulcers complicating repeated corneal transplants. Methods: The charts of all the patients that underwent repeated corneal transplantation between 1985 and 1998 were retrospectively reviewed for the presence of persistent epithelial defects and ulcers. The repeated corneal transplantation group included 122 regrafts performed in 80 patients. The follow-up period was at least 6 months after the last transplantation (average 31.5 months). Results: Persistent epithelial defects and/or corneal ulcers affected 31 of the 122 regrafts (25.4%) in 23 patients (29%). Of the repeated grafts, 18 had persistent epithelial defects, five had ulcers and eight had persistent epithelial defects complicated by ulcers. Nine of the 31 regrafts (29%) that developed persistent epithelial defects or ulcers had positive bacterial cultures. The survival proportion was similar for regrafts with persistent epithelial defects and with ulcers (p = 0.859), but lower in the regrafted group with persistent epithelial defects and ulcers compared with the entire repeated corneal transplantation group (p < 0.001). In ten patients (43%), one or several eyelid abnormalities and ocular surface disorders were identified. They were more common in repeated keratoplasties with epithelial defects or ulcers than in repeated keratoplasties without them (p < 0.0001). Persistent epithelial defects developed more commonly after cyclocryotherapy for refractory glaucoma (p = 0.001). Conclusions: Ulcers and persistent epithelial defects are common in repeated corneal transplantation and are associated with poor graft survival. Predisposing factors should be disclosed before regrafting and promptly treated.