Stromal Rejection Following Deep Anterior Lamellar Keratoplasty Surendra Basti*, Evan A. Olson*, Elmer Y. Tu** *Department of Ophthalmology, Northwestern University. Chicago, IL **Department of Ophthalmology, University of Illinois Eye and Ear Infirmary. Chicago, IL   Purpose and Rationale: To better characterize stromal rejection in the context of deep anterior lamellar keratoplasty(DALK) in order to facilitate early diagnosis and proper management. Since the confounding effect of endothelial rejection dues not exist, DALK is a good setting to study stromal rejection. Conclusions: The incidence of stromal rejection in DALK is clinically significant (5/20 patients in this study). DALK patients may benefit from corticosteroid regimens similar to those employed in penetrating keratoplasty. Stromal rejection may be more common in PKP than previously reported. Prompt recognition and aggressive treatment can result in good anatomic and visual outcomes. Methods: The clinical records of 22 patients undergoing deep anterior lamellar keratoplasty by two surgeons between October 2006 and January 2008 were reviewed to identify patients that experienced stromal rejection. The diagnosis was made after demonstration of acute stromal edema and/or stromal neovascularization in the absence of confounding preexisting conditions such as herpetic keratitis. The incidence, clinical features and management of stromal rejection were compared with other descriptions found in the literature. Figure 1 Figure 2 References: 1. Watson SL, Tuft SJ, Dart JK. Patterns of rejection after deep lamellar keratoplasty. Ophthalmology. 2006;113:556–560. 2. Patel SV, Hodge DO, Bourne WM. Corneal endothelium and postoperative outcomes 15 years after penetrating keratoplasty. Am J Ophthalmol. 2005;139:311-319. 3. Fontana L, Parente G, Tassinari G. Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus.  Am J Ophthalmol. 2007;143(1):117–124. 4. Noble, BA. Deep anterior lamellar keratoplasty (DALK): visual outcome and complications for a heterogeneous group of corneal pathologies. Cornea. 2007;26(1):59–64. 5. Watson SL, Ramsay A, Dart J, et al., Comparison of deep lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus. Ophthalmology. 2004;111:1676–1682. 6. Tan DT, Mehta JS. Future directions in lamellar corneal transplantation. Cornea. 2007;26(9 Suppl 1):S21–8. 7. Kawashima M, Mochizuki H, Kawakita T, et al. Presumed stromal graft rejection after automated lamellar therapeutic keratoplasty: case report. Journal of Medical Case Reports. 2007;1:10. 8. Al-Torbak A, Malak M, Teichmann K, et al. Presumed stromal graft rejection after deep anterior lamellar keratoplasty. Cornea. 2005;24:241–243. 9. Sarnicola V, Toro P, Gentile D, et al. Descemetic DALK and predescemetic DALK : outcomes in 236 cases of keratoconus. Cornea. 2010;29(1):53-59. 10. Ing JJ, Ing HH, Nelson LR, et al. Ten-year postoperative results of penetrating keratoplasty. Ophthalmology. 1998;105(10):1855-1865. 11. Epstein AJ, de Castro TN, Laibson PR, et al. Risk factors for the first episode of corneal graft rejection in keratoconus. Cornea. 2006;25(9):1005–1011. 12. Tuft ST, Gregory WM, Dawison CR. Bilateral penetrating keratoplasty for keratoconus. Ophthalmology. 1995;102:462–468. 13. Trigui A, Smauui M, Masmoudi J, et al. Corneal graft rejection: donor and receiver implication. J Fr Ophthalmol. 2005;28:631–634. 14. Price MO, Thompson RW Jr, Price FW Jr. Risk factors for various causes of failure in initial corneal grafts. Arch Ophthalmol. 2003;121:1087–1092. 15. Price FW Jr, Price DA, Ngakeng V, et al. Survey of steroid usage patterns during and after low-risk penetrating keratoplasty. Cornea. 2009;28(8):865-870. Figure 3 Figure 4 Figures 1-2: Diffuse slit lamp photos showing sectoral mid-stromal vascularization superiorly with peripheral stromal haze. Figure 3: High magnification view shows peripheral stromal haze suggestive of stromal rejection (arrowhead) with a concurrent epithelial rejection line (arrow). Figure 4: Stromal rejection usually presents with focal or sectoral injection Results: Twenty patients were included in the study. Five patients experienced stromal rejection within twelve months. Two patients were on low-dose corticosteroids when diagnosed. Four of the five patients were treated aggressively with q1-3 hourly prednisolone acetate 1.0% eye drops. The fifth was treated less aggressively with a maximum dose of only q6 hourly prednisolone acetate 1.0% and subsequently experienced a second rejection episode less than 5 months later. All episodes resolved completely with intense topical steroid treatment. Address for correspondence: Surendra Basti, MD. Northwestern University Feinberg School of Medicine, 675 N. St. Clair, Galter Suite 15-150. Chicago, IL 60611. Email: sbasti@northwestern.edu, Fax : (312) 503-8152, Tel : (312) 908-8152