1. The factors of involved in elevated intraocular pressure after the limbal transplantation (LT) Chiyoko Okamura, Syunji Yokokura, Megumi Uematsu, Akira Kubota, Toru Nakazawa, Nobuo Fuse, Koji Nishida Department of Ophthalmology and Visual Science Tohoku University Graduate School of Medicine

2. Objectives: １） How frequently the elevation IOP would occur after LT? 2 ） Which factors would be involved in the elevation IOP ? IOP:intraocular pressure LT:limbal transplantation

3. Materials and Methods ●Object of the 19 eyes of 19 patients who undertook LT （ involved in combined with surgical techniques) from June,2005 to August,2009 in Tohoku Uni Hospital. ●The actual IOP was measured at 1,2 and 3 months after surgery. ●We investigated how the primary disease,surgical techniques and the actual IOP would be involved with the elevation of IOP. ●Eleven eyes with PKP were served as control. ●Anterior chamber angle was investigated over 8 directions to clarify angle open distance(AOD 500 ) and whether or not there was the PAS with UBM. PKP:penetrating keratoplasty PAS:peripheral anterior synechia UBM:ultrasound biomicroscopy

4. The details of primary disease undertook PKP and LT ・ 11 eyes of patients (8 males and 3 females). ・ The mean age was 60.9±13.7 ※ ・ 19 eyes of patients (14 males and 5 females). ・ The mean age was 52.7±15.5 ※ ※ average±standard deviation

5. The details of combined surgical techniques with LT LKP ： lamellar keratoplasty AMT: amniotic membrane transplantation DLKP: deep lamellar keratoplasty

6. Evaluation method of anterior chamber angle with UBM a:UBM images of normal angle. b: Schematic representation of UBM anterior chamber angle measurement. X: scleral spur. Angle opening distance(AOD 500 =YZ)is defined as the length of the line drawn from the point on the corneal endothelial surface 500 μm anterior to X to the iris surface perpendicular to the corneal endothelial surface. Peripheral Anterior Synechiae and Ultrasound Biomicroscopic Parameters in Angle-Closure Glaucoma Suspects Chungkwon Yoo, Jong Hyun Oh, Yong Yeon Kim, and Hai Ryun Jung Korean J Ophthalmol. 2007 June; 21(2): 106–110. Published online 2007 June 20. doi: 10.3341/kjo.2007.21.2.106.

7. Preoperatively1 month2 months3 months PKP group9％9％ 9％9％ 0％0％ 0％0％ LT group 10.5 ％ 21.0 ％ 42.1 ％ PKP group and the comparison of the LT p=0.70p=0.38p=0.01 表１ 眼圧上昇の割合 Results ● Table1 The percentage of patients with IOP ＞ 21mmHg at preoperative,1, 2 and 3 months. (Fisher direct test) The number of the patients whose IOP was over 21 mmHg was significantly larger in LT group than in PKP group at two and three month after surgery （ p ＝ 0.01 ）.

8. LT+LKP 2 eyes LT+PKP 2 eyes LT+AMT 2 eyes LT+AMT+DLKP 1 eye alkali burn 2 eyes bullous keratopathy 1 eye gelatinous drop-like corneal dystrophy 1 eye Stevens-Johnson syndrome 1 eye burn 1 eye stem cells exhausted disease 1 eye 1)IOP in 7 of 19 eyes(36.7%) was more than 21mmHg after 3 postoperative months. 2)There were no obvious characters was in combined surgical techniques and primary disease which would increase IOP. Table2. Table3. Combined surgical techniques The details of primary disease

9. The evaluation of anterior chamber angle by UBM parameters （ AOD 500 ） Fig1. A comparison of the LT and PKP about AOD. LT group tended to narrow angle compared to PKP. （ LTgroup ： AOD150±210μm ＜ PKP group ： AOD240±155μm ） Fig2. A comparison of the IOP of 21mmHg or more groups and 21mmHg less than about AOD. IOP of 21mmHg or more group tended narrow angle compared to group of less than （ IOP21mmHg or more group ： AOD34.3±54. 5μm ＜ IOP21mmHg less than ： AOD148.4±162.9μm ）

10. The evaluation of PAS by UBM C:UBM images of PAS D:Schematic representation of PAS with UBM PAS over 270 degree was observed in 66.7%(8 of 12 eyes)of LT group, while in 9%(1 of 11 eyes)of PKP group （ P=0.0069 Fisher direct test). scleral spur

11. Discussion chronic inflammation before operation. ↓ PAS (less than 270 degree ) ↓ operative invasion (A)suture ligature of corneal limbus ↓ (B)hemostatic coagulation PAS (more than 270 degree) ↓ Elevated IOP (A)→ It was possible that because of being flat cornea,narrow angle was induced. (B)→operative scar involved aqueous venous around corneal limbus, so aqueous flow resistance was increased.

12. Conclusion Patients who underwent LT recognize elevation IOP, as its mechanism was suggested angle closure. We clarified that patients who undertook LT suffered from elevated IOP. It may be caused by angle closer.