title: Indications and outcomes of keratoplasties in children during a 40-year period.
abstract: OBJECTIVE
  To report the indications and the outcomes of keratoplasties in children over four decades.
  
  
  METHODS
  A retrospective cohort study of patients aged 16 years or younger who underwent keratoplasty in the Helsinki University Eye Hospital during 1968-2011. Diagnosis, preoperative status, age at the time of surgery, surgical technique, complications and follow-up time were registered. Main outcome measures were visual acuity and graft survival as assessed by Kaplan-Meier analysis. The independent role of risk factors on outcomes was evaluated by Cox multivariate regression analysis.
  
  
  RESULTS
  Forty-eight keratoplasties, 42 penetrating and six lamellar, were performed in 44 eyes of 39 children at the age of 4.5 months to 16 years (median, 12 years). Five patients had bilateral grafts, and five grafts were regrafts. The indication for keratoplasty was injury for 13 grafts, non-traumatic acquired corneal opacities for 11, keratoconus for eight, corneal dystrophy for seven, congenital corneal opacities for six and aniridia for three grafts. The cumulative proportion of clear grafts was 46% at 5 years postoperatively, and the median follow-up time of clear grafts was 5.1 years (range, 0.4-29 years) for 41 penetrating allografts (PKP). Simultaneous intraocular surgery at the time of grafting [hazard ratio (HR) 9.7], corneal vascularization (HR 8.1) and regrafting (HR 5.4) were the main independent risk factors for graft failure in this PKP cohort. The cumulative proportion of clear grafts was 84% at 5 years in the absence of any of these risk factors. PKP for keratoconus and corneal dystrophy yielded clear grafts in 83% of the eyes, and a visual acuity ≥0.3 (Snellen) in 75% of the eyes. Seventeen of the 20 graft failures were due to rejection.
  
  
  CONCLUSIONS
  Favourable graft survival was obtained in primary keratoplasties for non-vascularized corneal opacities performed without any other simultaneous intraocular surgery. Visual outcome was favourable in keratoconus and corneal dystrophies and poor in most eyes with injury.
authors.affiliation: Paediatric Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
authors.forename: Anna
authors.initials: A
authors.lastname: Majander
authors.affiliation: Ophthalmic Pathology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
authors.forename: Tero T
authors.initials: TT
authors.lastname: Kivelä
authors.affiliation: Department of Anterior Segment and Corneal Surgery Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
authors.forename: Kari
authors.initials: K
authors.lastname: Krootila
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003316:Corneal Diseases / Q000453:epidemiology* / Q000503:physiopathology / Q000601:surgery*; D016039:Corneal Transplantation; D005260:Female; D005387:Finland / Q000453:epidemiology; D006085:Graft Survival / Q000502:physiology*; D006801:Humans; D007223:Infant; D015948:Keratoplasty, Penetrating; D008297:Male; D011183:Postoperative Complications; D012086:Reoperation; D012189:Retrospective Studies; D014792:Visual Acuity / Q000502:physiology*
keywords: child; graft survival; keratoplasty; penetrating; risk factors; treatment outcome