gms | German Medical Science

Endothelial corneal allograft rejection (AR) is the most frequent cause of irreversible allograft opacity. Herein, we present a rare and special form of immunologic AR, the hyperacute stromal AR.

Retrospectively, 78 of 3641 patients were detected by means of the computer-assisted automated Erlangen operation system OPERA in the period from 1990 to 2003, who received a repeat penetrating keratoplasty (PK) after AR. Thereof 4 patients showed the picture of a hyperacute stromal AR. We describe the characteristic clinical and histopathological features.

Four patients, aged 63±12 years, received a PK because of different reasons (neuroparalytic corneal ulcer, traumatic endothelial decompensation, perforated cornea-iris-lens-injury, crystalline keratopathy). Four, 12, 18 and 57 months after PK (3x first PK, 1x third PK) a hyperacute AR occurred. The course of the disease was comparable in all patients: an acute beginning within a few days, a rapid progressive course, a diffuse, whitish leucocytic infiltration strictly constricted to the allograft and an intraocular inflammation with retrocorneal infiltration, but without hypopyon. A PK à chaud was performed in each patient. Histopathologically, a necrotizing, diffuse stromal keratitis with an infiltration mainly composed of neutrophilic granulocytes was present. Neither histopathologically nor microbiologically a pathogen could be verified. After 3, 9, 9 months or 10 1/2 years, respectively, the corneal allograft remained clear.

We described the characteristic clinical and histopathological picture of a special form of stromal immunologic AR with good prognosis after PK à chaud. Its knowledge is important for differentiation against infectious processes and for the resulting therapy as well as for the estimation of prognosis.