By Dr. Maria Severin, PD Dr. Karl Ulrich Bartz-Schmidt (auth.)
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Extra info for Penetrating Keratoplasty: Diagnosis and Treatment of Postoperative Complications
Ruusuvaara  introduced the concept that a subclinical immune reaction is responsible for the loss of endothelial cells following keratoplasty. He found a correlation between endothelial cell loss and HLA incompatibility. This discussion is still ongoing . The controversy might be resolved by specular microscopic follow-up examinations after rotation keratoplasty or autologous keratoplasty. The relevant literature [5, 11, 20, 24] , is not sufficient to clarify this question. However, it is important to obtain an answer in order to establish whether a cautiously dosed long-term therapy with steroids is justified even in transplants which do not appear to be at immunological risk.
7, pg. 66) . After keratoplasty on the second eye, an immune reaction is occasionally observed on the first eye (Chapter 1, pg. 1). As a rule keratoplasty is performed late on the second eye, namely only after the final result is available for the first eye. This means that an immune reaction of the endothelium will be diffuse. As a rule, there is only a mild endothelial reaction with precipitates confined to the transplant without stromal edema. 2 Non-immunological Origin It is difficult to assess non-immunological endothelial lesions since a continuous loss of endothelial cells occurs during the first three years following keratoplasty.
49). The epithelium may be intact. The process is slowly progressive. Reports in literature relate to single observations. Weakly virulent bacteria such as streptococcus C4-40 viridans are reported to be the cause of the infiltration. However, according to the observations of Weisenthal et al.  and Matsumoto et al. [5a] , fung i may also cause lesions of a sim ilar appearance. The crystalline arrangement is probably encouraged by the positioning between the stroma lamellae. Decisive for the diagnosis of this slowly progressive keratopathy is the crystalline appearance of the infiltrates in an eye free from inflammation .