Disparities in Visual Acuity Outcomes after Endothelial Keratoplasty – an IRIS® Registry Analysis

A Novel Artificial Endothelial Replacement Membrane for the Treatment of Chronic Corneal Edema

PURPOSE

The purpose of this study was to report the safety and efficacy results of an artificial lamellar implant for the treatment of chronic corneal edema.

METHODS

The EndoArt (EyeYon Medical, Ness Ziona, Israel), an artificial endothelial replacement membrane designed to treat corneal edema, was implanted in 24 eyes of 24 patients with low-to-normal visual potential. We present the safety and efficacy results from a prospective, open-label, single-arm, multicenter study conducted over a 12-month period.

RESULTS

Twenty-four patients were enrolled, with no device-related serious adverse events reported. Seventeen patients completed 12-month follow-up, showing a reduction in average central corneal thickness from 759 ± 116 μm to 613 ± 135 μm. Best-corrected distance visual acuity improved from 1.88 ± 0.79 logarithmic minimum angle of resolution (logMAR) to 1.34 ± 0.57 logMAR. Sixty percent gained at least 3 early treatment diabetic retinopathy study (ETDRS) lines. The EndoArt was removed in 5 cases due to incomplete attachment and replaced by corneal transplants; 1 patient was lost to follow-up, and 1 had a procedure failure. No device-related long-term complications, infections, or inflammations were reported. The implants remained transparent throughout the study.

CONCLUSIONS

The first-in-human results of EndoArt implantation demonstrated the device's potential to treat patients suffering from corneal edema with a favorable safety profile and effective edema reduction in most subjects, with no device-related serious adverse event. The EndoArt may offer a viable solution in regions facing a shortage of donor corneas, as well as for patients who have poor prognosis with human tissue.

Predictors of Health Care Disparities in Fuchs Dystrophy Treatment Using the IRIS Registry

PURPOSE

To evaluate associations between sociodemographic factors and surgical management in patients with Fuchs Endothelial Corneal Dystrophy (FECD).

METHODS

Patients >40 years old with FECD diagnosis and subsequent corneal edema between 2007 and 2020 were identified from the American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight). Multivariable Cox proportional hazards models were fit to examine the relationships between sociodemographic variables and time from FECD diagnosis to penetrating keratoplasty (PK) and endothelial keratoplasty (EK)/PK.

RESULTS

A total of 20,366 patients with FECD diagnosis and subsequent corneal edema were identified. Of the 4313 patients who underwent either EK or PK (any surgery), 374 patients underwent PK, 4037 underwent EK, and 98 received both interventions. After controlling for age, sex, and insurance status, Black or African American patients were 1.48 times as likely (hazard ratio 1.48, 95% confidence intervals (CI), 1.06-2.07) to undergo PK as compared with White patients and were less likely to receive any surgery (HR 0.83, 95% CI, 0.74-0.94). Asian patients were less likely (HR: 0.57, 95% CI, 0.43-0.75) to undergo any surgery. Female patients were more likely to undergo PK and less likely to undergo any surgery than male patients, and older patients were less likely to undergo any surgery with each increasing decade of life. There were no significant differences when stratified by insurance type.

CONCLUSIONS

Age, sex, race and ethnicity, and insurance type are associated with varying rates of different surgical interventions for FECD.

Predictive factors of long-term visual outcomes after primary Descemet's membrane endothelial keratoplasty (DMEK): retrospective study

PURPOSE

To determine predictive factors of higher levels of best-corrected visual acuity (BCVA) in the long-term after primary Descemet's membrane endothelial keratoplasty (DMEK).

METHODS

Retrospective, single-surgeon case series of 129 successful primary DMEK eyes without graft failure and with a minimum postoperative follow-up of 12 months. Mixed effect model for repeated measurements (MMRM) analysis was performed to determine recipient, donor, surgical and postoperative factors associated with BCVA ≤ 0.10 logMAR (≥ 20/25 Snellen).

RESULTS

After primary DMEK, there was a statistically significant improvement in BCVA with a global reduction in logMAR BCVA (p < 0.00001). There was also a global tendency towards increasing proportion of eyes with BCVA ≤ 0.10 logMAR at all time points (p < 0.00001), from 1.6% before DMEK to 64.4% in eyes with more than 5 years of F-U. Absence of retinal disease was associated with a decrease of 0.10 logMAR in postoperative BCVA after primary DMEK, maintaining constant the rest of variables (p < 0.001). The variables age (OR 0.960), postoperative time (OR 1.083), preoperative BCVA ≥ 0.375 logMAR (OR 0.162) and indication for DMEK (OR 5.412) were included in the predictive MMRM model of BCVA ≤ 0.10 logMAR.

CONCLUSION

Primary DMEK is associated with statistically and clinically significant improvement in BCVA that occur early in the postoperative period and are continuous over time. Eyes with retinal comorbidities have increased risk of worse postoperative BCVA after DMEK. Younger recipient age, Fuchs' dystrophy eyes and eyes with better preoperative BCVA are more likely to achieve postoperative BCVA ≤ 0.10 logMAR.

Outcomes and Early Complications Using an Endothelium-in Pull-Through Descemet Membrane Endothelial Keratoplasty Technique With Preloaded Versus Surgeon-Loaded Donor Tissue in Fuchs Patients

PURPOSE

This study aimed to compare outcomes and early complications using an endothelium-in pull-through Descemet membrane endothelial keratoplasty (DMEK) technique with preloaded versus surgeon-loaded donor tissue.

METHODS

Data from 163 eyes of 125 patients at the Wilmer Eye Institute diagnosed with Fuchs endothelial corneal dystrophy who underwent DMEK with or without cataract extraction using surgeon-loaded tissue (n = 83) or preloaded tissue (n = 80) were reviewed. Best-corrected visual acuity and early postoperative complications including small graft detachment (less than one third of the graft area), large graft detachment (more than one third), graft failure, and rebubbling were compared.

RESULTS

Baseline characteristics including age, sex, and visual acuity were not statistically different between the groups. Small graft detachment was observed in 18.1% of the surgeon-loaded and 22.5% of the preloaded group ( P = 0.48), whereas large detachment occurred in 12.0% and 5.0%, respectively ( P = 0.11). Among these, rebubbling was performed in 18 (21.7%) in the surgeon-loaded compared with 12 (15.0%) in the preloaded group ( P = 0.27). The rebubbling rate of the combined procedure (cataract surgery and DMEK) was 21.8% and of DMEK alone was 7.7% ( P = 0.048). Primary graft failure occurred in 2 surgeon-loaded cases (2.4%) and 1 preloaded case (1.3%) ( P = 0.58). There was no difference in postoperative best-corrected visual acuity at 1 year (logarithm of the minimum angle of resolution 0.21 ± 0.25 for the surgeon-loaded vs. 0.16 ± 0.16 for the preloaded group, P = 0.23).

CONCLUSIONS

DMEK surgery using preloaded endothelium-in tissue has comparable outcomes with surgeon-loaded endothelium-in tissue. However, there was a trend toward the lower rebubbling rate in DMEK alone compared with combined procedures.

Suture Fixation to Reduce Graft Detachment in Descemet Stripping Endothelial Keratoplasty

PURPOSE

The aim of this study was to report the outcomes of graft fixation using interrupted, full-thickness sutures on graft detachment after Descemet stripping endothelial keratoplasty (DSEK).

METHODS

All DSEK procedures performed at Mayo Clinic, Rochester, MN, from 2015 through 2022 were retrospectively reviewed. Risk factors for graft detachment were defined as previous incisional glaucoma surgery, previous penetrating keratoplasty, or absence of the normal lens-capsule barrier. Cases were categorized into sutured, high-risk grafts; unsutured, high-risk grafts; and unsutured, low-risk grafts. The primary outcome was graft detachment, and secondary outcomes were early graft failure and graft clarity at 12 months after surgery.

RESULTS

Demographics between the high-risk groups were similar for sex and age at the time of surgery. Graft detachment occurred in 4 of 97 sutured, high-risk eyes (4.1%) and 24 of 119 unsutured high-risk eyes (20.2%) ( P = 0.002). In comparison, graft detachment occurred in 18 of 181 unsutured low-risk eyes (9.9%). The incidence of early graft failure was 2.1%, 5.0%, and 3.3% and late graft failure by 12 months was 9.8%, 12.8%, and 4.2%, respectively.

CONCLUSIONS

In eyes with high-risk factors for graft detachment, suture fixation of the graft in DSEK decreased graft detachment to a rate at least as low as that in low-risk eyes.

Rebubbling and graft detachment in Descemet membrane endothelial keratoplasty using a standardised protocol

OBJECTIVES

To analyse risk factors and long-term outcomes after rebubbling and graft detachment in Descemet membrane endothelial keratoplasty (DMEK).

METHODS

176 consecutive DMEK grafts of 125 patients performed by 8 surgeons with a standardised technique between January 2015 and July 2022 were analysed. Main outcome measures were graft detachments, rebubbling rate, postoperative outcomes, and risk factors for graft failure and rebubbling.

RESULTS

6 (3.4%) grafts required rebubbling (>1/3 area detached). 40 (22.7%) grafts developed self-resolving partial detachments (<1/3 area detached). The mean time to rebubble was 16 ± 9.4 days. Mean BSCVAs at 5 years postoperative were 0.03 ± 0.16, 0.03 ± 0.14, and 0.15 ± 0.31 logMAR in fully attached, partially detached and rebubbled grafts (P = 0.437). 5-year graft survival were 98%, 90%, and 83% in fully attached, partially detached and rebubbled eyes (P = 0.02). There was significantly greater endothelial cell loss (ECL) in the rebubbled eyes (P = 0.018). Intraoperative trauma was a risk factor for graft failure (HR 1.81; 95% CI: 1.33-2.50; P = 0.023). An indication for surgery other than Fuchs endothelial dystrophy was a risk factor for rebubbling (HR 5.28; 95% CI: 5.11-72.4; P = 0.007).

CONCLUSION

DMEK grafts had better graft survival if there was no partial detachment or rebubbling at 5 years postop. There was significant ECL associated with rebubbling. A standardised technique reduces rebubbling and graft failure risk.

Current social determinants of health and social risk factors in conditions of the cornea: a scoping review

PURPOSE OF REVIEW

To achieve health equity in eye health and vision care, social determinants of health (SDoH) and the associated social risk factors must be addressed. To address SDoH and social risk factors in ophthalmology, they must first be identified. The purpose of this review was to determine the SDoH and social risk factors in conditions of the cornea that have most recently been explored.

RECENT FINDINGS

This review identified social risk factors associated with all five domains of SDoH, as outlined by Healthy People 2030. The neighborhood and built environment was the domain identified the most for both exploration and observation. The social and community context domain was the least explored, and healthcare access and quality and social and community context domains were the least observed. The cornea condition explored the most in relation to SDoH was dry eye syndrome.

SUMMARY

The findings from this review can inform clinicians on the social risk factors that could be screened for in eye care facilities, so patients can be connected with services to minimize the impact of social risk factors on cornea conditions. Furthermore, the findings have identified cornea conditions and domains of SDoH that are understudied which can be an area for future studies by vision researchers.

Predictors of Receiving Keratoplasty for Fuchs' Endothelial Corneal Dystrophy among Medicare Beneficiaries

PURPOSE

To identify factors associated with receipt of endothelial keratoplasty (EK) and penetrating keratoplasty (PK) in patients with Fuchs' endothelial corneal dystrophy (FECD).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Medicare beneficiaries 65 years of age or older with a FECD diagnosis between 2011 and 2019.

METHODS

The 100% Medicare fee-for-service administrative claims database was queried for treatment-naïve FECD patients. A multivariate logistic regression model including age, race and ethnicity, sex, geography, ocular comorbidities and surgeries, Charlson comorbidity index (CCI), and socioeconomic status was used to identify factors associated with receipt of EK and PK. Kaplan-Meier survival analyses were used to determine the rate of EK after cataract or complex or other anterior segment surgery.

MAIN OUTCOME MEASURES

Factors associated with receipt of an EK or PK, plus rate of EK after cataract or complex or other anterior segment surgery.

RESULTS

Of 719 066 beneficiaries identified, 31 372 (4.4%) received an EK and 2426 (0.3%) received a PK. In a multivariate analysis, female sex decreased likelihood of both EK and PK (adjusted odds ratio 0.83 [95% confidence interval 0.81-0.85] and 0.84 [0.78-0.92], respectively), while Western residence (1.33 [1.29-1.38]; 1.25 [1.11-1.42]) compared to Southern and history of complex or other anterior segment surgery (1.62 [1.54-1.70]; 5.52 [4.97-6.12]) increased the likelihood of both. Compared to Whites, the likelihood of EK was decreased for Black (0.76 [0.72-0.80]), Asian or Pacific Islander (0.54 [0.48-0.61]), and Hispanic or Latino (0.62 [0.55-0.70]) race and ethnicity, while for the same groups likelihood of PK was increased (for Black 1.32 [1.14-1.53]; Asian/Pacific Islander 1.46 [1.13-1.89]; and Hispanic/Latino 1.62 [1.25-2.11]). Following cataract or complex/other anterior segment surgery, rates of EK were 1.3% and 3.3% at 1 year and 2.3% and 5.6% at 8 years, respectively.

CONCLUSIONS

In a multivariate analysis, women beneficiaries are less likely to receive EK or PK for FECD compared with men, whereas non-White beneficiaries are less likely to receive EK and more likely to receive PK compared with White beneficiaries.

Risk Factors for Repeat Keratoplasty after Endothelial Keratoplasty - an IRIS® Registry Analysis

PURPOSE

To assess risk factors for repeat keratoplasty after endothelial keratoplasty (EK).

DESIGN

Retrospective cohort study METHODS: : EK procedures performed between 2013-2018 in the IRIS® Registry (Intelligent Research in Sight) were identified.

STUDY POPULATION

Patients aged 18 years and older who underwent EK.

MAIN OUTCOME MEASURES

1) Risk factors for repeat keratoplasty, and 2) complication rates after EK. A Kaplan-Meier survival analysis was used to determine the probability of repeat keratoplasty. A multivariable shared frailty survival model was used to assess risk factors.

RESULTS

59,344 procedures were identified in the registry, of which 30,600 EK procedures met the inclusion criteria for the analysis. The probability of repeat keratoplasty was 17.4% (95% CI:16.7-18.0%) at five years. Risk factors for repeat keratoplasty include post-operative re-bubbling procedure (HR 2.24, 95% CI:2.05-2.45); prior failed graft (HR 2.07, 95% CI:1.84-2.32) or bullous keratopathy (HR 1.47, 95% CI:1.33-1.61) versus Fuchs dystrophy as surgical indication; subsequent routine cataract surgery (HR 1.61, 95% CI:1.45-1.79); as well as subsequent (HR 1.53, 95% CI:1.39-1.69) and prior/concurrent (HR 1.23, 95% CI:1.11-1.36) glaucoma surgery or history of glaucoma (HR 1.24, 95% CI:1.14-1.35). Medicaid (HR 1.47, 95% CI:1.13-1.92), military/government (HR 1.29, 95% CI:1.03-1.60), Medicare Fee-for-Service (HR 1.17, 95% CI:1.05-1.31) or Medicare Managed (HR 1.17, 95% CI:1.01-1.36) insurances versus private insurance, as well as Black versus White race (HR 1.25, 95% CI:1.11-1.40) and smoking (HR 1.16, 95% CI:1.05-1.27) were also associated with an increased risk of undergoing repeat keratoplasty.

CONCLUSIONS

Black race, government-based insurance plans, and smoking were identified as independent factors associated with repeat keratoplasty in addition to history of glaucoma, glaucoma surgery, and prior graft failure or bullous keratopathy as surgical indication.