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New Measures for the Prophylaxis of Immune Reactions after Penetrating Keratoplasty
Reinhard T., Sundmacher R.,
Heinrich-Heine-Universität Düsseldorf, Universitäts-Augenklinik (Düsseldorf)
Immune reactions are still main complication after penetrating keratoplasty, in normal-risk as well as in high-risk indications. At the moment, standard measure in normal-risk and high-risk indications is topical application of steroids, furthermore, in high-risk indications systemic application of Cyclosporin A. The following improvements should be considered in the next years: 1. Topical immunomodulation: Normal-risk as well as high-risk patients may possibly benefit from topical application of FK506. 2. Systemic immunomodulation: For high-risk indications systemic Mycophenolate mofetil already represents an effective alternative to systemic Cyclosporin A. Future studies must show if results can be further improved by long-term application of this drug over 24 instead of 6 to 12 months as performed at the moment. Furthermore, clinical studies will be performed evaluating combinations of systemic immunosuppressives as Rapamycin/Mycophenolate mofetil or Rapamycin/Cyclosporin A already successfully tested in the rat keratoplasty model. A further promising immunosuppressive being tested in the rat keratoplasty model is FTY720. 3. HLA-Matching: This neglected prophylactic measure will be further improved within the next years for normal-risk as well as for high-risk indications. This will concern consideration of split antigens in the major histocompatibility complex. Furthermore, relative importance of mismatches (taboo versus permissible) will be defined in the next years. Finally, the role of the minors must be investigated in clinical studies. 4. Transfection of corneal grafts: Here, the aim is to achieve an (elevated) expression of inhibitory cytokines by graft endothelial cells. Since only experimental, but no clinical studies are available it is impossible at the moment to forecast if this measure will gain clinical importance.