Repeat keratoplasty in failed Descemet stripping automated endothelial keratoplasty

Comparison of Glaucoma Therapy Escalation After Penetrating Keratoplasty to Descemet Stripping Automated Endothelial Keratoplasty for the Treatment of Pseudophakic Bullous Keratopathy: A Cohort Study

PURPOSE

The purpose of this study was to compare glaucoma therapy escalation (GTE), graft survival, vision, and glaucoma following penetrating keratoplasty (PK group) and Descemet stripping automated endothelial keratoplasty (DSAEK group) to treat pseudophakic bullous keratopathy (PBK).

METHODS

This cohort included cases of PBK managed with PK from 2009 to 2014. We compared the incidences and determinants of GTE, graft survival, and visual disability. P < 0.05 was statistically significant.

RESULTS

There were 58 eyes in the PK group and 117 eyes in the DSAEK group. The incidence of GTE in the PK and DSAEK groups at the last follow-up was 34.2% (95% confidence interval [CI]: 19.5-48.9) and 46.6% (95% CI: 27.7-65.4), respectively. The risk of GTE was similar between the groups (relative risk [RR] = 1.36 [95% CI: 0.94-1.98], P = 0.12). GTE was significantly associated with graft survival in the PK group (RR = 3.25 [95% CI: 1.5-7.0], P < 0.001) and the DSAEK group (RR = 3.77 [95% CI: 2.6-5.6], P < 0.001). Glaucoma (P = 0.001) and previous keratoplasty (P < 0.001) were significant predictors for GTE. At the final follow-up visit, severe visual disability was not significantly different between the groups (RR = 0.9 [95% CI: 0.3-2.9], P = 0.88). There was a statistically significant improvement in vision after DSAEK (P < 0.001) but not after PK (P = 0.67).

CONCLUSION

GTE was similar in eyes with PBK managed by PK or DSAEK. Glaucoma and previous keratoplasty were predictors of GTE post-keratoplasty. DSAEK gave better visual outcomes than PK for managing PBK.

Secondary Endothelial Keratoplasty-A Narrative Review of the Outcomes of Secondary Corneal Endothelial Allografts

BACKGROUND

We review the literature on the efficacy and safety outcomes of secondary Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK).

METHODS

Literature search of English-written publications up to September 27, 2020 in PubMed database, using the terms "endothelial keratoplasty" in combination with keywords "secondary" or "repeat." In addition, we manually searched the references of the primary articles.

RESULTS

Twenty-seven studies (n = 651 eyes) were retained and reviewed, including 10 studies on repeat DSEK, 8 studies on repeat DMEK, 6 studies of DMEK following DSEK, and 3 studies of DSEK after failed DMEK. All studies reported significant improvement in visual acuity after secondary endothelial keratoplasty (EK). Twelve studies compared visual outcomes between primary and secondary EK, reporting conflicting findings. Sixteen studies reported endothelial cell loss rates after secondary EK, and only 1 study reported significantly increased endothelial cell loss rates compared with primary EK. Allograft rejection episodes occurred in 1.8% of eyes (range, 0%-50%). Six studies compared complication rates between primary and secondary EK eyes, and only 1 study found a higher median number of complications. However, 2 studies reported higher regraft failure rates compared with primary EK eyes.

CONCLUSIONS

Secondary EK is surgically feasible and renders significant visual improvement after failed primary EK, although it is not clear whether visual outcomes and allograft survival are comparable with primary EK, raising the question of whether secondary EK eyes are "low risk" as primary EK eyes. Further larger, prospective studies are encouraged to obtain additional quality data on secondary corneal endothelial allotransplantation.

Graft detachments in endothelial keratoplasty

Graft detachment is the most common complication of endothelial keratoplasty. With the ongoing advancements in the field of endothelial keratoplasty, our understanding of risk factors of graft detachments and its management has been evolving. Various prevention measures have been described in literature including presoaking the donor graft, anterior chamber tamponade, venting incisions, sutures to prevent dislocation of graft. Management of a detached graft involves secondary interventions such as rebubbling, suturing and regrafts. In this review, we discuss graft detachment in different types of endothelial keratoplasty techniques including Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty; with emphasis on incidence, risk factors, preventive measures and their management.