Keratoplasty in the United States: Trends and Indications From 2015 to 2020

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.

Descemet Membrane Endothelial Keratoplasty for Endothelial Failure in Primary Angle Closure Suspects

PURPOSE

To analyze the feasibility and outcome of Descemet membrane endothelial keratoplasty (DMEK) for treatment of endothelial failure in primary angle closure suspect (PACS) eyes.

METHODS

Retrospective, single-center case series of eyes treated by DMEK for endothelial failure caused by PACS. Main study parameters were success rate of DMEK, best-corrected visual acuity, anterior chamber depth, central corneal thickness, and endothelial cell density. Mean follow-up time was 16 ± 13 months.

RESULTS

Ten eyes of 9 patients receiving DMEK for the treatment of corneal endothelial failure because of PACS were included. Except for 2 eyes that had undergone cataract surgery, none of the eyes had previous ocular surgery. DMEK combined with cataract surgery was performed in 5 eyes, DMEK alone with second-step cataract surgery in 2 eyes. The eyes with corneal edema after cataract surgery received DMEK only. DMEK surgery was successful in nine out of 10 eyes, 1 patient required repeat DMEK because of primary graft failure. In the group of phakic eyes, mean preoperative internal anterior chamber depth was 1.74 ± 0.18 mm. In eyes with corneal edema, central corneal thickness was 849 ± 205 μm before DMEK surgery, and 517 ± 24 μm at the final postoperative visit (P = 0.002).

CONCLUSIONS

DMEK is a feasible option in eyes with endothelial failure because of primary angle closure. In case of advanced corneal edema, a second-step procedure (first DMEK, second cataract surgery) is a possible approach if visibility of the lens is too poor for simultaneous cataract surgery.

Post-Keratoplasty Microbial Keratitis in the Era of Lamellar Transplants-A Comprehensive Review

Microbial keratitis in a post-transplant cornea should be considered a distinct entity from microbial keratitis in a non-transplant cornea. Firstly, the use of immunosuppressive treatments and sutures in corneal transplants changes the etiology of keratitis. Secondly, corneal transplant has an impact on corneal biomechanics and structure, which facilitates the spread of infection. Finally, the emergence of lamellar transplants has introduced a new form of keratitis known as interface keratitis. Given these factors, there is a clear need to update our understanding of and management strategies for microbial keratitis following corneal transplantation, especially in the era of lamellar transplants. To address this, a comprehensive review is provided, covering the incidence, risk factors, causes, and timing of microbial keratitis, as well as both clinical and surgical management approaches for its treatment in cases of penetrating and lamellar corneal transplants.

Corneal blindness in the developing world: The role of prevention strategies

Corneal blindness is an important contributor to the burden of global blindness and has a greater prevalence in low-income countries of the developing world where resources and infrastructure are limited. The causes of corneal blindness too are different from high-income countries and include infectious keratitis, ocular trauma, and xerophthalmia. Persons with these indications tend to have unfavourable outcomes after corneal transplantation, limiting their chances of benefitting from this sight-saving procedure. However, most causes of corneal blindness in the developing world are preventable. This highlights the importance of understanding the unique challenges in these regions and the need for targeted interventions. This article discusses various prevention strategies, including primordial, primary, and secondary prevention, aimed at reducing the burden of corneal blindness in low-income countries. These include capacity building, training, and awareness campaigns to reduce the risk factors of ocular trauma, infectious keratitis, and to improve access to first aid. It is also important to promote safe eye practices and tackle nutritional deficiencies through public health interventions and policy changes. Providing the required training to general ophthalmologists in the management of basic corneal surgeries and diseases and enhancing the accessibility of eye care services in rural areas will ensure early treatment and prevent sequelae. Current treatment modalities belong to the tertiary level of prevention and are largely limited to corneal transplantation. In developing nations, there is a scarcity of donor corneal tissue necessitating an urgent expansion of eye banking services. Alternative approaches to corneal transplantation such as 3D printed corneas, cultured stem cells, and biomaterials should also be explored to meet this demand. Thus, there is a need for collaborative efforts between healthcare professionals, policymakers, and communities to implement effective prevention strategies and reduce the prevalence of corneal blindness in the developing world.

Main issues in penetrating keratoplasty

This review explores contemporary challenges in penetrating keratoplasty (PK), focusing on technical intricacies, technological advancements, and strategies for preventing graft rejection. A systematic literature search from January 2018 to July 2023 was conducted across PubMed, Cochrane, Web of Science, Scopus, and EMBASE. The inclusion criteria comprised studies on PK and its comparison with other corneal pathologies, with emphasis on keratoconus (KC). Two independent reviewers screened studies, extracting relevant data. The review covers PK evolution, highlighting infra-red femtosecond lasers' impact on graft shapes, minimizing astigmatism, and enhancing wound healing. Graft rejection, a primary complication, is examined, detailing risk factors and preventive measures. Preoperative considerations, diagnostic techniques for rejection, and PK in KC are discussed. Postoperative care's significance, including intraocular pressure monitoring and steroid administration, is emphasized. The paper concludes with a comprehensive approach to prevent graft rejection, involving topical and systemic medications. An outlook on evolving monoclonal antibody research is presented. As the field progresses, personalized approaches and ongoing therapeutic exploration are expected to refine strategies, enhancing PK outcomes.