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

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.

Demographic Profile and Clinical Characteristics of Fuchs Endothelial Corneal Dystrophy in Thai Patients: A Retrospective Cohort in a Tertiary Referral Center

Purpose

To describe the demographic profile, clinical characteristics, and treatment trends of Fuchs endothelial corneal dystrophy (FECD) in Thai patients, reflecting the evolving landscape of corneal transplantation in this region.

Patients and Methods

This retrospective cohort study included 900 patients (1,743 eyes) diagnosed with FECD at a tertiary referral center in Thailand between January 2017 and June 2023. Demographic, clinical, and surgical data were analyzed, focusing on best-corrected visual acuity (BCVA), central corneal thickness (CCT), endothelial cell density (ECD), surgical interventions, and graft survival rate.

Results

The mean age was 63.9 years, with 77.2% of patients being female. Most eyes were classified as Adamis grade I (83.7%). Diabetes mellitus and hypertension were prevalent in 17.4% and 38.6% of patients, respectively. The rate of corneal transplantation was 8.1%, with DMEK accounting for 69.3% of transplants. Graft survival rates were 94.3% at 1 year and 76.2% at 5 years. The average post-operative ECD declined from 1667.8 ± 668.0 cells/mm² at 1 year to 1140.7 ± 684.4 cells/mm² at 5 years. Cataract surgery was performed in 20.4% of phakic eyes, with only 2.2% requiring corneal transplantation within five years.

Conclusion

FECD in Thailand, as reflected by this large cohort, predominantly presents at an early stage, allowing for conservative management. The growing use of DMEK highlights the shift towards less invasive procedures, mirroring global trends in Southeast Asia. These findings emphasize the importance of advancing surgical techniques and improving eye banking practices in the region.

Imaging pathology in archived cornea with Fuchs' endothelial corneal dystrophy including tissue reprocessing for volume electron microscopy

Fuchs' endothelial corneal dystrophy (FECD) is a common sight-threatening condition characterised by pathological changes in the posterior cornea. Here we report observations by light, transmission and volume scanning electron microscopy on changes in the endothelium and matrix associated with the characteristic deformations of Descemet's membrane, termed guttae. Specimens were archived full-thickness human corneal tissue, removed during graft surgery, that had been fixed, stained and embedded by conventional processing methods for examination by transmission electron microscopy more than 40-years previously. Intact archived samples can be extremely valuable where, as with FECD, new cell-based methods of therapy now avoid excision of the full cornea thickness and any tissue excised is inferior for study. Volume electron microscopy, in particular serial block face scanning electron microscopy (SBF SEM), employing backscatter electron detection from resin-embedded specimens, has become an invaluable technique for 3D imaging of biological samples. However, archived specimens are normally considered unsuitable for imaging as conventional processing methods generate low backscatter electron yield. To overcome this for SBF SEM, we subjected epoxy resin-embedded specimens to de-plastination, then applied additional contrasting agents, uranyl acetate and lead acetate, prior to re-embedding. Selected regions of interest in the new resin blocks were examined in a scanning electron microscope equipped for SBF SEM and serial image datasets acquired. Enhanced contrast enabled 3D reconstruction of endothelium and guttae in Descemet's membrane over large tissue volumes.

Demographic and Systemic Risk Factors for Persistent Corneal Edema Following Cataract Surgery in Patients With and Without Diabetes

PURPOSE

To identify risk factors associated with the development of corneal edema (CE) and the need for corneal transplantation following cataract surgery.

DESIGN

Retrospective cohort study.

METHODS SETTING

Nation-wide sample of Medicare beneficiaries from 2011-2015.

STUDY POPULATION

Medicare beneficiaries aged over 65 years who received cataract surgery between 2011-2014 with at least 1 year of continuous follow-up. Data was retrieved from the Denominator and Physician Supplier Part B file from the Center for Medicare and Medicaid Services.

MAIN OUTCOME(S) AND MEASURE(S)

The main outcome was the association between demographic characteristics (e.g., age, sex, race/ethnicity) and systemic factors including diabetes status, hypertension, and tobacco use on the incidence of CE and the subsequent need for corneal transplantation following cataract surgery.

RESULTS

Among 187,746 beneficiaries, 67,734 had diabetes and 120,012 did not. Beneficiaries with diabetes were more likely to develop CE compared to those without (Odds ratio [OR] 1.19, 95% Confidence Interval [CI] [1.02-1.40]). Compared to those aged 65-74, beneficiaries aged 75-84 and over 85 were more likely to develop CE (OR 1.29 [1.09-1.52]) and OR 1.96 [1.55-2.46], respectively). Asian (OR 2.42 [1.66-3.40]), Hispanic (OR 2.60 [1.73-3.74]), and North American Native (OR 3.59 [1.78-6.39]) race was associated with increased likelihood of developing CE. North American Native beneficiaries had higher risk of requiring corneal transplantation compared to White beneficiaries (OR 9.30 [2.26-25.31]). Female sex decreased likelihood of requiring corneal transplantation post-operatively (OR 0.56 [0.36-0.87]). Amongst those with diabetes, the presence of proliferative diabetic retinopathy increased the likelihood of developing CE (OR 1.94 [1.05-3.39]).

CONCLUSION

Older age, diabetes, and non-White race elevate the risk of CE following cataract surgery, with race incurring the highest risk. Further research is needed to understand the factors underlying the significantly increased risk of CE in racial and ethnic minorities within the United States.

Neuropeptide alpha-Melanocyte stimulating hormone preserves corneal endothelial morphology in a murine model of Fuchs dystrophy

Fuchs endothelial corneal dystrophy is a heterogenous disease with multifactorial etiology, and genetic, epigenetic, and exogenous factors contributing to its pathogenesis. DNA damage plays a significant role, with ultraviolet-A (UV-A) emerging as a key contributing factor. We investigate the potential application of neuropeptide α-melanocyte stimulating hormone (α-MSH) in mitigating oxidative stress induced endothelial damage. First, we examined the effects of α-MSH on a cultured human corneal endothelial cell line (HCEnC-21T) exposed to hydrogen peroxide (H2O2) induced oxidative DNA damage. We performed immunofluorescence and flow cytometry to assess DNA damage and cell death in the cultured cells. Additionally, we used an established mouse model that utilizes ultraviolet light to induce corneal endothelial cell damage resulting in decreased CEnC number, increased cell size variability, and decreased percentage of hexagonal cells. This endothelial decompensation leads to an increase in corneal thickness. Following UV-A exposure, the mice were systemically treated with α-MSH, either immediately after exposure (early treatment) or beginning two weeks post-exposure (delayed treatment). To evaluate treatment efficacy, we analyzed CEnC density and morphology using in vivo confocal microscopy, and central corneal thickness using anterior segment optical coherence tomography. Our findings demonstrated that α-MSH treatment effectively protects HCEnC-21T from free-radical induced oxidative DNA damage and subsequent cell death. In vivo, α-MSH treatment, mitigated the loss of CEnC density, deterioration of cell morphology and suppression of the resultant corneal swelling. These results underline the potential application of α-MSH as a therapeutic agent for mitigating corneal endothelial damage.

Trends of Surgery, Patient, and Surgeon Characteristics for Corneal Transplants in the Medicare Population From 2011 to 2020

PURPOSE

The aim of this study was to describe recent trends in corneal transplants and patient and surgeon characteristics for corneal transplants that occurred in the Medicare population.

METHODS

This was a retrospective, cross-sectional study using Current Procedural Terminology codes. We identified Medicare Fee-For-Service (FFS) claims for different types of corneal transplant procedures performed on Medicare beneficiaries aged 65 years or older from 2011 to 2020. Number and types of corneal transplants performed each year and patient and surgeon demographics and characteristics were analyzed.

RESULTS

We analyzed 148,981 corneal transplants performed by 2972 surgeons within the study period. Most corneal transplants performed were endothelial keratoplasties (70.1%). Most patients were women (60.3%) and White (85.8%). 18.2% of patients lived in a rural area, whereas only 3.5% of transplants occurred in a rural area and 5% of surgeons practiced in a rural area. Male surgeons represented 77.8% of all surgeons and performed 84.9% of all corneal transplants in the study period. The proportion of corneal transplants performed by female surgeons gradually increased over time, from 12.1% in 2011 to 19.0% in 2020. The proportion of female surgeons also increased from 16.2% in 2011 to 23.8% in 2020. Most surgeons (67%) performed <6 corneal transplants per year.

CONCLUSIONS

Although the number of female corneal transplant surgeons has increased over time, women remain underrepresented in the surgical workforce. Further investigation should be conducted to identify the underlying reason and address the identified disparities within the landscape of corneal transplantation.

Prevalence and Economic Burden of Fuchs Endothelial Corneal Dystrophy in the Medicare Population in the United States

PURPOSE

The aim of this study was to assess the prevalence and economic burden of Fuchs endothelial corneal dystrophy (FECD) in patients older than 65 years in the United States.

METHODS

A retrospective analysis of the Medicare data reported to the Vision and Eye Health Surveillance System including patients diagnosed with FECD between 2014 and 2019 was performed. The crude prevalence rate of FECD was assessed and extrapolated to estimate the total case burden in the United States. The prevalence data were further compared between men and women and different racial groups. In addition, the economic burden was computed using inflation-adjusted direct costs of treatment to patients.

RESULTS

The Medicare database included 25,432,700 patients older than 65 years. The national prevalence of FECD in this population cohort was calculated to be 1.12% in 2019. In 2019, FECD case burden in Medicare patients older than 65 years was 284,846 and total estimated FECD case count in the country in this age group was 591,226. FECD prevalence was significantly higher in women as compared to men during the 6-year period evaluated in this study. The intergroup comparison revealed that FECD prevalence in the White population was significantly higher than all other racial groups ( P < 0.0001). The total inflation-adjusted economic burden of FECD in the United States in 2019 was USD 291.648 million and has increased from USD 243.998 million over the 6-year study period.

CONCLUSIONS

The estimated prevalence of FECD in the individuals older than 65 years is 1.12% in the United States. FECD prevalence is significantly higher in women and White population compared with other ethnicities.

Early Endophthalmitis Incidence and Risk Factors after Glaucoma Surgery in the Medicare Population from 2016 to 2019

PURPOSE

To determine early endophthalmitis incidence and risk factors after glaucoma surgeries in the Medicare population.

DESIGN

Retrospective, longitudinal study.

PARTICIPANTS

Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries in the United States aged 65 years or older undergoing glaucoma surgery.

METHODS

Medicare claims were used to identify all patients who underwent glaucoma, cataract, or combined cataract/glaucoma surgery from 2016 to 2019. Endophthalmitis cases within 42 days of the index surgery were identified using the diagnostic codes. Multivariable logistic regression models were used to evaluate factors associated with postoperative endophthalmitis.

MAIN OUTCOME MEASURES

The 42-day postoperative endophthalmitis incidence and risk factors associated with endophthalmitis after glaucoma surgery.

RESULTS

There were 466 928 glaucoma surgeries, of which 310 823 (66.6%) were combined with cataract surgery. Cataract surgeries alone (n = 8 460 360) served as a reference group. Microinvasive glaucoma surgeries constituted most glaucoma procedures performed (67.8%), followed by trabeculectomy (14.0%), tube shunt (10.9%), and other procedures (7.3%). There were 572 cases of endophthalmitis identified after all glaucoma surgeries. Endophthalmitis incidence after glaucoma, combined cataract/glaucoma, and cataract surgeries alone was 1.5 (95% confidence interval [CI], 1.3-1.7), 1.1 (95% CI, 1.0-1.2), and 0.8 (95% CI, 0.8-0.8) per 1000 procedures, respectively. The median day of diagnosis of endophthalmitis was later for glaucoma surgeries (16.5 days) compared with combined cataract/glaucoma or cataract surgeries alone (8 and 6 days, respectively). Compared with microinvasive glaucoma surgery (MIGS), tube shunts were the only surgery type to be a significant risk factor for endophthalmitis for both stand-alone (adjusted odds ratio [aOR], 1.8, P = 0.002) and combined surgery (aOR 1.8, P = 0.047). The other risk factor for both stand-alone (aOR 1.1, P = 0.001) and combined (aOR 1.06, P = 0.049) surgeries was the Charlson Comorbidity Index (CCI). Age (aOR 1.03, P = 0.004) and male gender (1.46, P = 0.001) were significant risk factors for combined cataract and glaucoma surgeries.

CONCLUSIONS

Compared with cataract surgery, early endophthalmitis incidence was higher for both glaucoma and combined cataract/glaucoma surgeries, with the highest incidence among tube shunts.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Comparison of Black and Non-Black Patients in the Presentation and Treatment of Keratoconus

Purpose

Patients with advanced keratoconus (KCN) are less likely to benefit from corneal cross-linking and may require a partial or full thickness keratoplasty. This study aimed to determine whether racial disparities exist in the clinical presentation and initial treatment recommendations for patients evaluated for KCN.

Methods

A single-center retrospective review was conducted on all patients who presented to the cornea department for initial evaluation of KCN between 2018 and 2020. Patients who had undergone prior corneal procedures or surgeries were excluded. Baseline sociodemographic and clinical information was collected and stratified according to black versus non-black race. Generalized estimating equations were used to examine the association between black race and presenting corrected distance visual acuity (CDVA), presence of corneal scarring, keratometry values, Belin ABCD score, and treatment recommendations. Multivariate models were adjusted for patient demographics.

Results

A total of 128 patients (251 eyes) were included in this study. In fully adjusted models, black individuals presented with significantly worse CDVA (p < 0.0001) and worse tomographic KCN staging according to the Belin ABCD criteria (p = 0.002) compared to non-blacks. Blacks were also more than four times as likely to present with a thinnest pachymetry <400 µm (p < 0.0001) and more than three times as likely to have corneal scarring (p = 0.001). Blacks were more than seven times more likely to have keratoplasty recommended as treatment than conservative management such as corneal cross-linking or contact lenses (p = 0.004).

Conclusion

Compared with their non-black counterparts, blacks presented with significantly more advanced KCN, which placed them at risk of requiring more invasive treatment plans. Future studies should investigate reasons for such late presentations and aim to mitigate disparities in the presentation and management of KCN.

Clinical Outcomes of Toric Intraocular Lenses in Patients with Fuchs Endothelial Corneal Dystrophy

INTRODUCTION

Implantation of toric intraocular lenses (IOLs) in patients with Fuchs endothelial corneal dystrophy (FECD) is still considered relatively contraindicated, without sufficient clinical evidence. Therefore, this study was designed to evaluate the results of toric IOL implantation in patients with FECD.

METHODS

A retrospective case-control study of 28 eyes of FECD patients and 84 eyes of healthy control patients who received toric IOLs during routine cataract surgery was performed. The outcome measures were uncorrected and corrected distance visual acuity, spherical equivalent, and refractive residual astigmatism.

RESULTS

The mean postoperative uncorrected and corrected distance visual acuity in the FECD eyes compared to the control eyes were 0.15 ± 0.14 vs. 0.13 ± 0.17, respectively (P = 0.32), and 0.05 ± 0.08 vs. 0.06 ± 0.10, respectively (P = 0.95). The spherical equivalent in the FECD eyes compared to the control eyes was - 0.29 ± 0.43 vs. - 0.21 ± 0.50, respectively (P = 0.19). The preoperative corneal centroid astigmatism in the FECD eyes compared to the control eyes was 0.85 D@93° ± 2.42° vs. 0.23 D@68° ± 2.50°, respectively (P = 0.43), and the mean preoperative corneal astigmatism magnitude was 2.26 ± 1.1 D vs. 2.28 ± 1.03 D, respectively (P = 0.82). A trend toward higher postoperative refractive centroid astigmatism was found in the FECD eyes compared with the control eyes: 0.24 D@28° ± 0.57° vs. 0.03 D@127° ± 0.53°, respectively (P = 0.09). However, the mean refractive astigmatism magnitude was similar in FECD eyes and the healthy control eyes: 0.52 ± 0.31 D vs. 0.42 ± 0.31 D, respectively (P = 0.44) (D diopters).

CONCLUSION

The postoperative refractive astigmatism (both centroid astigmatism and mean magnitude astigmatism) was no higher than 0.52 D in both groups. Therefore, FECD patients without corneal edema can be considered for toric IOLs.