A 5-year analysis of endothelial vs penetrating keratoplasty graft survival in Chinese patients

Penetrating Keratoplasty: Indications and Graft Survival by Geographic Region

Corneal transplantation, or penetrating keratoplasty (PK), is the most common form of solid-organ transplantation performed worldwide. Here, we evaluated the indications for PK and rates of transplant survival around the world by geographic region. We conducted a literature search of PubMed, MEDLINE, and Google Scholar databases and identified 155 relevant studies from 41 countries published between 1987 and 2021. The most common indications for PK were keratoconus in Europe, Africa, the Middle East, Australia, New Zealand, and Central and South America, bullous keratopathy in North America, and corneal scarring in Asia. The overall global mean graft survival rates at 1-, 2-, 3-, 5-, and 10-years were 88.6%, 81.2%, 78.9%, 72.8%, and 61.2%, respectively. Through this systematic analysis of PK by region, we hope to bring a new perspective to the corneal transplantation literature and to potentially highlight global differences and unmet needs in patient care.

Determinants of Glaucoma Therapy Escalation After Descemet-Stripping Automated Endothelial Keratoplasty To Treat Pseudophakic Bullous Keratopathy: A Nested Case-Control Study

Purpose:

To study the determinants of glaucoma therapy escalation (GTE) after Descemet-stripping automated endothelial keratoplasty (DSAEK) for pseudophakic bullous keratopathy in an eye-care hospital in Saudi Arabia.

Methods:

This nested case-control study evaluated patients who required medical or surgical treatment for controlling glaucoma after DSAEK (defined as GTE; GTE group). A group of patients who did not require any intervention post-DSAEK served as controls (control group). Data were collected on preoperative, intraoperative, and postoperative parameters for DSAEK. Variables were compared between groups to evaluate risk factors for GTE and graft failure.

Results:

The study sample comprised 117 eyes (40 in the GTE group and 77 in the control group). Glaucoma was present in 20 (17.1%) of the eyes before DSAEK. The median duration of follow-up was 27 months [Interquartile range (IQR): 24; 42]. Intraoperative complications occurred in 4 eyes, and 2 eyes had a decentered donor button. Graft failure causing vision impairment and GTE at the final follow-up were noted in 19 (16.2%) and 40 (34.2%) eyes, respectively. Glaucoma prior to DSAEK was significantly associated with GTE [odds ratio (OR) = 6.4; 95% confidence interval (CI) 2.4; 18.3; P = 0.0004]. A history of penetrating keratoplasty (PK) was significantly associated with GTE after DSAEK [OR = 6.2 (95% CI 1.5; 24.7) P = 0.008]. At the last visit, GTE and graft failure were positively associated (OR = 27.2, P < 0.005).

Conclusion:

Escalation of glaucoma therapy was warranted in one in 3 eyes that had undergone DSAEK. GTE and graft failure are interrelated complications. Patients with glaucoma and PK have a higher risk of GTE post-DSAEK.

Considerations for Corneal Surgery With Patients in the 10th Decade of Life

PURPOSE

The purpose of this study was to report the indications, ocular and systemic comorbidities, and surgical outcomes of corneal transplantation in patients older than 90 years.

METHODS

A retrospective review was conducted to identify individuals 90 years and older who underwent corneal transplantation surgery at the Bascom Palmer Eye Institute between January 2013 and October 2020. Outcomes included best-corrected visual acuity and graft survival over time. Paired t tests were used to compare visual acuity preoperatively versus postoperatively. Graft survival was evaluated with Kaplan-Meier curves.

RESULTS

Fifty-eight eyes of 52 consecutive individuals were included. The mean age of individuals was 92 ± 2 years; 26.9% were male; and 48.1% self-identified as non-Hispanic White and 38.5% as Hispanic. Postoperative follow-up was 14.7 ± 12.1 months. Of the 58 eyes, 44.8% (26/58) underwent penetrating keratoplasty, 46.6% (27/58) Descemet stripping automated endothelial keratoplasty, and 6.9% (4/58) keratoprosthesis. All surgeries were performed under monitored local anesthesia, without major complications. Surgical indications included pseudophakic bullous keratopathy (36.2%), glaucoma-associated corneal decompensation (27.6%), Fuchs endothelial dystrophy (25.9%), and perforated corneal ulceration (19.0%). The best-corrected visual acuity improved by 0.32 (95% confidence interval 0.14-0.50; P < 0.01) as early as 1 month postoperatively, and vision gains were sustained for at least 12 months. Graft survival probability at 12 months was 88%.

CONCLUSIONS

Corneal transplantation is a safe and successful procedure in restoring the visual acuity for patients older than 90 years after careful preoperative evaluation. Further research is needed to evaluate the impact of corneal transplantation on quality of life in patients in the 10th decade of life.

Rose Bengal Photodynamic Antimicrobial Therapy: A review of the intermediate term clinical and surgical outcomes

PURPOSE

To evaluate the intermediate term clinical outcomes of Rose Bengal Photodynamic Antimicrobial Therapy (RB-PDAT) for infectious keratitis. Secondarily, to evaluate the surgical outcomes of individuals that underwent optical keratoplasty after RB-PDAT.

DESIGN

Retrospective cohort study.

METHODS

Retrospective chart review of 31 eyes from 30 consecutive individuals with infectious keratitis refractory to standard medical therapy who underwent RB-PDAT at the Bascom Palmer Eye Institute between January 2016 and July 2020. Data collected included demographics, risk factors for infectious keratitis, microbiological diagnosis, Best Spectacle-Corrected Visual Acuity (BCVA), clinical outcomes after RB-PDAT and complication rates post-keratoplasty. RB-PDAT was performed as described in previous studies. Graft survival was evaluated using Kaplan Meier curves with log-ranks in individuals that underwent keratoplasty after RB-PDAT.

RESULTS

Mean age of the study population was 53±18.0 years. 70% were female; 53.3% self-identified as non-Hispanic White; 43.3% as Hispanic. Mean follow-up time was 28.0±14.4 months. Risk factors included contact lens use (80.6%), history of infectious keratitis (19.3%), and ocular surface disease (16.1%). Cultures were positive for Acanthamoeba (51.6%), Fusarium (12.9%), and Pseudomonas (6.5%). 22.5% of individuals with Acanthamoeba infection were treated with concomitant Miltefosine. Clinical resolution was achieved in 77.4% of individuals on average 2.72±1.85 months after RB-PDAT with 22.5% requiring therapeutic penetrating keratoplasties and 54.8% subsequently requiring optical penetrating keratoplasties. At 2 years, the overall probability of graft survival was 78.7% and the graft failure rate was 21.3%.

CONCLUSION

RB-PDAT is a potential adjunct therapy for infectious keratitis that may reduce the need for a therapeutic penetrating keratoplasty. Cases that undergo keratoplasty after RB-PDAT may have a higher probability of graft survival at one year postoperatively.

A 20-year bibliometric analysis of Fuchs endothelial corneal dystrophy: from 2001 to 2020

PURPOSE

The aim of this study was to identify trends and focuses in the field of Fuchs endothelial corneal dystrophy (FECD) research.

METHODS

A bibliometric analysis based on the Web of Science Core Collection was conducted. All publications related to FECD from 2001 to 2020 were extracted and analyzed. VOSviewer v.1.6.17 was used to construct a visualization map and evaluate the trends and focuses in FECD research.

RESULTS

A total of 1,041 publications were extracted. The rate of global publications has steadily increased. The United States produced the highest number of publications (461), the highest number of citations (18,757), and the highest H index (69). Melles GRJ published the highest number of papers (60), and Price FW had the highest number of citations (4,154) in the FECD research field. The highest number of publications came from the journal Cornea (279). Keywords were classified into four clusters: (1) corneal transplantation surgery, (2) surgical techniques and instruments, (3) corneal parameter measurement, and (4) genetic and molecular pathomechanisms. The average appearing years (AAYs) of the keywords were evaluated. Recently appearing keywords included "Tcf4 gene" (AAY of 2018.3), "ctg18.1" (AAY of 2017.2), "trinucleotide repeat expansion" (AAY of 2018.3), "rock inhibitor" (AAY of 2017.4), and "descemetorhexis" (AAY of 2017.4).

CONCLUSIONS

The United States has a dominant position in FECD research. Although corneal transplantation surgery has been the most mainstream area of FECD research field for a long time, gene mutations such as the TCF4 CTG trinucleotide repeat expansion, nonsurgical interventions such as rho-associated kinase inhibitors, and newer surgical methods such as descemetorhexis without endothelial keratoplasty are potential research hotspots.

Feasibility and Outcomes of Corneal Transplantation Performed at Rural Centers: An Extension of the Pyramidal Model of Enhanced Eye Care at Rural Outreach

PURPOSE

The aim of this study was to report on the feasibility of setting up a system of corneal transplants at rural outreach centers and report the outcomes of the first 111 cases.

METHODS

Retrospective analysis of the outcomes of corneal transplantation performed on patients with optical indications between March 2016 and September 2019 at 4 secondary (rural) centers. The centers are a part of a network in the pyramidal model developed by L V Prasad Eye Institute. The graft clarity and best-corrected visual acuity (BCVA) at 1-year follow-up were analyzed.

RESULTS

Of the 111 patients, 34.23% underwent penetrating keratoplasty and 65.77% endothelial keratoplasty. The mean age was 59.4 ± 15.0 (range-17-86 years); 47.75% were men and 52.25% were women. The indications for surgery were bullous keratopathy (54.05%), corneal scar/adherent leukoma (23.42%), and repeat grafts (13.51%). At the end of 1 year, 69.37% grafts remained clear. Factors associated with graft failure included poor socioeconomic status and graft infiltrate in both univariate and multivariate analyses. Surgical technique of endothelial keratoplasty was associated with failure on multivariate analysis only. Of the 77 eyes with clear corneal grafts at 1 year, the preoperative mean logMAR BCVA was 1.91 ± 0.06, which improved to 0.90 ± 0.08 postoperatively. Overall, 84.4% had preoperative BCVA of <3/60. Postoperatively, 40% had BCVA of 6/18 or better.

CONCLUSIONS

Our study showed that close to 70% grafts remained clear at 1 year. Graft failure was associated with poor socioeconomic status and graft infiltrates. This study established a viable model for delivery of corneal transplant surgery and care in a rural setup.