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O'Brien RC, Ishwaran H, Szczotka-Flynn LB, Lass JH. Random Survival Forests Analysis of Intraoperative Complications as Predictors of Descemet Stripping Automated Endothelial Keratoplasty Graft Failure in the Cornea Preservation Time Study. JAMA Ophthalmol 2021; 139:191-197. [PMID: 33355637 DOI: 10.1001/jamaophthalmol.2020.5743] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance A new analytic method can evaluate factors of interest associated with graft failure after Descemet stripping automated endothelial keratoplasty (DSAEK) or more generally in any ophthalmic surgical setting with a time-to-event outcome. Objective To reanalyze types of intraoperative complications associated with DSAEK graft failure in the Cornea Preservation Time Study using random survival forests. Design, Setting, and Participants This cohort study, initially conceived in April 2019, used a prediction model to conduct a post hoc secondary analysis of data collected in a multicenter, double-masked, randomized clinical trial. Forty US clinical sites with 70 surgeons participated, with donor corneas provided by 23 US eye banks. The study included 1090 participants, representing 1330 eyes, undergoing DSAEK for Fuchs dystrophy (1255 eyes [94.4%]) or pseudophakic or aphakic corneal edema (75 eyes [5.6%]). Enrollment occurred between April 16, 2012, and February 20, 2014, and follow-up ended June 5, 2017. Statistical analysis was performed from July 10, 2019, to May 29, 2020. Intervention Descemet stripping automated endothelial keratoplasty with random assignment of a donor cornea with preservation time of 7 days or less or 8 to 14 days. Main Outcomes and Measures Ranked variable importance for intraoperative complications among 50 donor, recipient, and eye bank variables and restricted mean survival time through 47 months (1434 days) after DSAEK were examined. Random survival forests, a nonparametric method (with less restrictive model assumptions) that is far more flexible in its ability to model nonlinear effects and interactions, was used to analyze the data. Results This study included 1090 participants (663 women [60.8%]; median age, 70 years [range, 42-90 years]), representing 1330 eyes. Random survival forests ranked a DSAEK intraoperative complication as the third most predictive factor of graft failure, after surgeon and eye bank, in the final model with 5 predictors. In the first 47 months after DSAEK, the estimated mean difference in restricted mean survival time for grafts that experienced a DSAEK intraoperative complication vs those that did not was -227 days (99% CI, -352 to -70 days) based on the final RSF model. Conclusions and Relevance These findings, while post hoc, support the hypothesis that random survival forests allow for an improved analytic approach for identifying factors predictive of graft failure and for obtaining adjusted graft survival estimates. Random survival forests offer the opportunity to guide the development of future population-based cohort ophthalmic surgical studies, establishing definitive factors for procedural success.
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Affiliation(s)
- Robert C O'Brien
- Department of Data Science, University of Mississippi Medical Center, Jackson
| | - Hemant Ishwaran
- Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, Florida
| | - Loretta B Szczotka-Flynn
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio.,University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jonathan H Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio.,University Hospitals Cleveland Medical Center, Cleveland, Ohio
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O'Brien RC, Szczotka-Flynn LB, Lass JH. A Clarification and Call for a National Keratoplasty Registry. JAMA Ophthalmol 2021; 139:2778628. [PMID: 33856421 DOI: 10.1001/jamaophthalmol.2021.0716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Robert C O'Brien
- Department of Data Science, University of Mississippi Medical Center, Jackson
| | - Loretta B Szczotka-Flynn
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, Ohio
| | - Jonathan H Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, Ohio
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Szczotka-Flynn LB, Shovlin JP, Schnider CM, Caffery BE, Alfonso EC, Carnt NA, Chalmers RL, Collier S, Jacobs DS, Joslin CE, Kroken AR, Lakkis C, Pearlman E, Schein OD, Stapleton F, Tu E, Willcox MDP. American Academy of Optometry Microbial Keratitis Think Tank. Optom Vis Sci 2021; 98:182-198. [PMID: 33771951 PMCID: PMC8075116 DOI: 10.1097/opx.0000000000001664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
SIGNIFICANCE Think Tank 2019 affirmed that the rate of infection associated with contact lenses has not changed in several decades. Also, there is a trend toward more serious infections associated with Acanthamoeba and fungi. The growing use of contact lenses in children demands our attention with surveillance and case-control studies. PURPOSE The American Academy of Optometry (AAO) gathered researchers and key opinion leaders from around the world to discuss contact lens-associated microbial keratitis at the 2019 AAO Annual Meeting. METHODS Experts presented within four sessions. Session 1 covered the epidemiology of microbial keratitis, pathogenesis of Pseudomonas aeruginosa, and the role of lens care systems and storage cases in corneal disease. Session 2 covered nonbacterial forms of keratitis in contact lens wearers. Session 3 covered future needs, challenges, and research questions in relation to microbial keratitis in youth and myopia control, microbiome, antimicrobial surfaces, and genetic susceptibility. Session 4 covered compliance and communication imperatives. RESULTS The absolute rate of microbial keratitis has remained very consistent for three decades despite new technologies, and extended wear significantly increases the risk. Improved oxygen delivery afforded by silicone hydrogel lenses has not impacted the rates, and although the introduction of daily disposable lenses has minimized the risk of severe disease, there is no consistent evidence that they have altered the overall rate of microbial keratitis. Overnight orthokeratology lenses may increase the risk of microbial keratitis, especially secondary to Acanthamoeba, in children. Compliance remains a concern and a significant risk factor for disease. New insights into host microbiome and genetic susceptibility may uncover new theories. More studies such as case-control designs suited for rare diseases and registries are needed. CONCLUSIONS The first annual AAO Think Tank acknowledged that the risk of microbial keratitis has not decreased over decades, despite innovation. Important questions and research directions remain.
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Affiliation(s)
| | | | | | | | - Eduardo C Alfonso
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicole A Carnt
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Sarah Collier
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Deborah S Jacobs
- Massachusetts Eye and Ear, Cornea Service, Harvard Medical School, Boston, Massachusetts
| | - Charlotte E Joslin
- Department of Ophthalmology and Visual Science, College of Medicine, Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Abby R Kroken
- School of Optometry, University of California, Berkeley, Berkeley, California
| | | | - Eric Pearlman
- Departments of Ophthalmology, and Physiology and Biophysics, University of California, Irvine, Irvine, California
| | - Oliver D Schein
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fiona Stapleton
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Elmer Tu
- University of Illinois Eye and Ear Infirmary, Chicago, Illinois
| | - Mark D P Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
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Efron N, Brennan NA, Chalmers RL, Jones L, Lau C, Morgan PB, Nichols JJ, Szczotka-Flynn LB, Willcox MD. Authors' Reply: "Thirty years of 'quiet eye' with etafilcon A contact lenses: Additional considerations". Cont Lens Anterior Eye 2020; 44:101345. [PMID: 32624361 DOI: 10.1016/j.clae.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Nathan Efron
- Institute of Health and Biomedical Innovation, School of Optometry and Vision Science, Queensland University of Technology, Australia.
| | | | | | - Lyndon Jones
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Charis Lau
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Philip B Morgan
- Eurolens Research, Division of Pharmacy and Optometry, The University of Manchester, UK
| | - Jason J Nichols
- The University of Alabama at Birmingham, School of Optometry, Birmingham, AL, USA
| | - Loretta B Szczotka-Flynn
- University Hospitals Eye Institute, University Hospitals Cleveland Medical Center, Department of Ophthalmology & Visual Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Mark D Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Berg EJ, Ying GS, Maguire MG, Sheffield PE, Szczotka-Flynn LB, Asbell PA, Shen JF. Climatic and Environmental Correlates of Dry Eye Disease Severity: A Report From the Dry Eye Assessment and Management (DREAM) Study. Transl Vis Sci Technol 2020; 9:25. [PMID: 32821497 PMCID: PMC7401914 DOI: 10.1167/tvst.9.5.25] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 01/27/2020] [Indexed: 02/01/2023] Open
Abstract
Purpose Correlate climate, weather parameters, and environmental exposures with the severity of symptoms and signs of dry eye disease (DED) in Dry Eye Assessment and Management (DREAM) study participants. Methods Participants from five distinct climates completed the Ocular Surface Disease Index (OSDI) and were examined for corneal and conjunctival staining, tear breakup time (TBUT), and Schirmer's testing at baseline, 3, 6, and 12 months. Climate, weather parameters, and pollutants including ozone (O3), carbon monoxide (CO), nitrous oxides (NO2, NOx, NOy), sulfur dioxide (SO2), particulate matter, and optical depth were obtained from governmental databases. Multivariate analysis and partial correlation coefficients (ρ) were used to assess associations, adjusted for age, sex, and the presence of Sjögren disease. Results Among 535 participants, 81% were female and mean age was 58 years. Participants from the Mediterranean climate demonstrated better corneal fluorescein staining, better TBUT, and higher Schirmer's test scores throughout the calendar year (each P < 0.0001). Greater corneal fluorescein staining was associated with lower humidity (P < 0.0038). TBUT measurements positively correlated with temperature, humidity, and dewpoint and inversely correlated with NO2 levels (P < 0.0038). Paradoxically, some airborne pollutants were associated with less severe signs of dry eye (P < 0.0038). Windspeed was not correlated with signs of DED, and OSDI scores did not correlate with individual environmental exposures. Conclusions Dry eye signs differed between climates and local humidity levels. With the exception of NO2, airborne pollutants were not associated with detrimental dry eye features. Translational Relevance These results support limiting dry air exposure for patients with DED.
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Affiliation(s)
| | - Gui-shuang Ying
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA
| | - Maureen G. Maguire
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA
| | - Perry E. Sheffield
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Penny A. Asbell
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joanne F. Shen
- Department of Ophthalmology, Mayo Clinic, Scottsdale, AZ, USA
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Efron N, Brennan NA, Chalmers RL, Jones L, Lau C, Morgan PB, Nichols JJ, Szczotka-Flynn LB, Willcox MD. Thirty years of 'quiet eye' with etafilcon A contact lenses. Cont Lens Anterior Eye 2020; 43:285-297. [PMID: 32278644 DOI: 10.1016/j.clae.2020.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/27/2020] [Accepted: 03/28/2020] [Indexed: 11/17/2022]
Abstract
Frequent replacement contact lenses made from the etafilcon A hydrogel lens material were introduced onto the market over 30 years ago, and etafilcon A remains the most widely used hydrogel lens material today. Although the prescribing of silicone hydrogel lenses is increasing, millions of lens wearers globally have been wearing hydrogel lenses for many years and exhibit a physiologically-stable 'quiet eye', with a low profile of adverse events. Hydrogel lenses are demonstrated to maintain a low inflammatory response and infection risk profile during daily wear, which in the case of etafilcon A, may be related to its low modulus, and the naturally-protective, anti-microbial, non-denatured lysozyme absorbed into the lens from the tear fluid. Although improved corneal physiology from decreased hypoxia with silicone hydrogel lenses is well accepted, equivalent levels of corneal oxygenation are maintained during daily wear of low to medium powered hydrogel lenses, which do not impede the daily corneal de-swelling process, and do not induce clinically significant changes in ocular health. Therefore, hydrogel lenses remain an important alternative for daily wear in modern contact lens practice.
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Affiliation(s)
- Nathan Efron
- Institute of Health and Biomedical Innovation, School of Optometry and Vision Science, Queensland University of Technology, Australia.
| | | | | | - Lyndon Jones
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, ON, Canada
| | - Charis Lau
- Johnson & Johnson Vision, Inc, Jacksonville, FL, USA
| | - Philip B Morgan
- Eurolens Research, Division of Pharmacy and Optometry, The University of Manchester, UK
| | - Jason J Nichols
- The University of Alabama at Birmingham, School of Optometry, Birmingham, AL, USA
| | - Loretta B Szczotka-Flynn
- University Hospitals Eye Institute, University Hospitals Cleveland Medical Center, Department of Ophthalmology & Visual Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Mark D Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Berg EJ, Ying GS, Maguire MG, Sheffield PE, Szczotka-Flynn LB, Asbell PA, Shen JF. Climatic and Environmental Correlates of Dry Eye Disease Severity: A Report From the Dry Eye Assessment and Management (DREAM) Study. Transl Vis Sci Technol 2020; 9:25. [PMID: 32821497 DOI: 10.1167/tvst.9.5.2525tvst-19-1699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 01/27/2020] [Indexed: 05/25/2023] Open
Abstract
PURPOSE Correlate climate, weather parameters, and environmental exposures with the severity of symptoms and signs of dry eye disease (DED) in Dry Eye Assessment and Management (DREAM) study participants. METHODS Participants from five distinct climates completed the Ocular Surface Disease Index (OSDI) and were examined for corneal and conjunctival staining, tear breakup time (TBUT), and Schirmer's testing at baseline, 3, 6, and 12 months. Climate, weather parameters, and pollutants including ozone (O3), carbon monoxide (CO), nitrous oxides (NO2, NOx, NOy), sulfur dioxide (SO2), particulate matter, and optical depth were obtained from governmental databases. Multivariate analysis and partial correlation coefficients (ρ) were used to assess associations, adjusted for age, sex, and the presence of Sjögren disease. RESULTS Among 535 participants, 81% were female and mean age was 58 years. Participants from the Mediterranean climate demonstrated better corneal fluorescein staining, better TBUT, and higher Schirmer's test scores throughout the calendar year (each P < 0.0001). Greater corneal fluorescein staining was associated with lower humidity (P < 0.0038). TBUT measurements positively correlated with temperature, humidity, and dewpoint and inversely correlated with NO2 levels (P < 0.0038). Paradoxically, some airborne pollutants were associated with less severe signs of dry eye (P < 0.0038). Windspeed was not correlated with signs of DED, and OSDI scores did not correlate with individual environmental exposures. CONCLUSIONS Dry eye signs differed between climates and local humidity levels. With the exception of NO2, airborne pollutants were not associated with detrimental dry eye features. TRANSLATIONAL RELEVANCE These results support limiting dry air exposure for patients with DED.
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Affiliation(s)
| | - Gui-Shuang Ying
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA
| | - Maureen G Maguire
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA, USA
| | - Perry E Sheffield
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Penny A Asbell
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joanne F Shen
- Department of Ophthalmology, Mayo Clinic, Scottsdale, AZ, USA
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Aldave AJ, Terry MA, Szczotka-Flynn LB, Liang W, Ayala AR, Maguire MG, O'Brien RC, Benetz BA, Bokosky JE, Dunn SP, Gillette TE, Hammersmith KM, Hardten DR, Jeng BH, Jones MF, Lindstrom RL, Maverick KJ, Nirankari VS, Oliva MS, Raber IM, Rapuano CJ, Rosenwasser GO, Ross KW, Seedor JW, Shamie N, Stoeger CG, Tauber S, Van Meter WS, Verdier DD, Lass JH. Effect of Graft Attachment Status and Intraocular Pressure on Descemet Stripping Automated Endothelial Keratoplasty Outcomes in the Cornea Preservation Time Study. Am J Ophthalmol 2019; 203:78-88. [PMID: 30849341 DOI: 10.1016/j.ajo.2019.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/25/2019] [Accepted: 02/22/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the association of donor, recipient, and operative factors on graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS) as well as the effects of graft dislocation and elevated IOP on graft success and endothelial cell density (ECD) 3 years postoperatively. DESIGN Cohort study within a multi-center, double-masked, randomized clinical trial. METHODS 1090 individuals (1330 study eyes), median age 70 years, undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (6% of eyes). Recipient eyes receiving donor corneal tissue randomized by preservation time (PT) of 0-7 days (N = 675) or 8-14 days (N = 655) were monitored for early or late graft failure through 3 years. Donor, recipient, operative, and postoperative parameters were recorded including graft dislocation (GD), partial detachment, and pre- and post-operative IOP. Pre- and postoperative central donor ECD were determined by a central image analysis reading center. Proportional hazards, mixed effects, and logistic regression models estimated risk ratios and (99% confidence intervals). RESULTS Three independent predictive factors for GD were identified: a history of donor diabetes (odds ratio [OR]: 2.29 [1.30, 4.02]), increased pre-lamellar dissection central corneal thickness (OR: 1.13 [1.01, 1.27] per 25µ increase), and operative complications (OR: 2.97 [1.24, 7.11]). Among 104 (8%) eyes with GD, 30 (28.9%) developed primary donor or early failure and 5 (4.8%) developed late failure vs. 15 (1.2%; P < .001) and 29 (2.4%; P = .04), respectively, of 1226 eyes without GD. 24 (2%) of 1330 study eyes had early acutely elevated postoperative IOP that was associated with a higher risk of graft failure through 3 years (hazard ratio: 3.42 [1.01, 11.53]), but not with a lower mean 3-year ECD (mean difference 61 (-479, 601) cells/mm2, P = .77). History of elevated postoperative IOP beyond 1 month was not significantly associated with 3-year graft success or ECD. CONCLUSIONS Donor diabetes, increased donor corneal thickness, and intraoperative complications were associated with an increased risk of GD. Early acutely elevated postoperative IOP and GD significantly increased the risk for graft failure following DSAEK.
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Rosenwasser GO, Szczotka-Flynn LB, Ayala AR, Liang W, Aldave AJ, Dunn SP, McCall T, Navarro LC, Pramanik S, Ross KW, Stulting RD, Terry MA, Tu EY, Verdier DD, Kollman C, Gal RL, Beck RW, Lass JH. Effect of Cornea Preservation Time on Success of Descemet Stripping Automated Endothelial Keratoplasty: A Randomized Clinical Trial. JAMA Ophthalmol 2019; 135:1401-1409. [PMID: 29127431 DOI: 10.1001/jamaophthalmol.2017.4989] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Demonstrating that success of Descemet stripping automated endothelial keratoplasty is similar across donor cornea preservation times (PTs) could increase the donor pool. Objective To determine whether the 3-year rate of graft success using corneal donor tissue preserved 8 to 14 days is noninferior to that of donor tissue preserved 7 days or less. Design, Setting, and Participants A multicenter, double-masked, randomized noninferiority clinical trial was conducted from April 16, 2012, to June 5, 2017, at 40 clinical sites (70 surgeons) in the United States, with donor corneas provided by 23 US eye banks. A total of 1090 individuals (1330 study eyes) underwent Descemet stripping automated endothelial keratoplasty (1255 eyes [94.4%] for Fuchs endothelial corneal dystrophy). Interventions Descemet stripping automated endothelial keratoplasty with random assignment of a donor cornea with a PT of 7 days or less (0-7d PT) or 8 to 14 days (8-14d PT). Main Outcomes and Measures Graft success at 3 years. Results Of the 1090 participants (1330 study eyes; 60.2% women and 39.8% men; median age at enrollment, 70 years [range, 42-90 years]), the 3-year cumulative probability of graft success was 95.3% (95% CI, 93.6%-96.9%) in the 0-7d PT group and 92.1% (95% CI, 89.9%-94.2%) in the 8-14d PT group (difference, 3.2%). The upper limit of the 1-sided 95% CI on the difference was 5.4%, exceeding the prespecified noninferiority limit of 4%. The difference was mostly owing to more primary donor failures in the 8-14d PT group, with the conditional probability of failure after the first month being 2.4% in the 0-7d PT group and 3.1% in the 8-14d PT group. In preplanned secondary analyses, longer PT was associated with a lower rate of graft success (unadjusted hazard ratio for graft failure per additional day of PT, 1.10; 95% CI, 1.03-1.18; P = .008 [PT analyzed as days]), with success rates of 96.5% (95% CI, 92.3%-98.4%) for PT of 4 days or less, 94.9% (95% CI, 92.5%-96.6%) for PT of 5 to 7 days, 93.8% (95% CI, 91.0%-95.8%) for PT of 8 to 11 days, and 89.3% (95% CI, 84.4%-92.7%) for PT of 12 to 14 days (P = .01 [PT analyzed as categorical variable]). Conclusions and Relevance The 3-year success rate in eyes undergoing Descemet stripping automated endothelial keratoplasty was high irrespective of PT. However, the study was unable to conclude that the success rate with donor corneas preserved 8 to 14 days was similar to that of corneas preserved 7 days or less with respect to the prespecified noninferiority limit. Although longer PT was associated with a lower success rate, the difference in rates was small when PT was less than 12 days.
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Affiliation(s)
| | - Loretta B Szczotka-Flynn
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio,University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Wendi Liang
- Jaeb Center for Health Research, Tampa, Florida
| | | | | | | | | | | | | | | | | | - Elmer Y Tu
- University of Illinois Chicago Eye and Ear Infirmary, Chicago
| | | | | | - Robin L Gal
- Jaeb Center for Health Research, Tampa, Florida
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
| | - Jonathan H Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio,University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Lass J, Benetz BA, Verdier DD, Szczotka-Flynn LB, Ayala AR, Liang W, Aldave AJ, Dunn SP, McCall T, Mian SI, Navarro LC, Patel SV, Pramanik S, Rosenwasser GO, Ross KW, Terry MA, Kollman C, Gal RL, Beck RW. Corneal Endothelial Cell Loss 3 Years After Successful Descemet Stripping Automated Endothelial Keratoplasty in the Cornea Preservation Time Study: A Randomized Clinical Trial. JAMA Ophthalmol 2019; 135:1394-1400. [PMID: 29127432 DOI: 10.1001/jamaophthalmol.2017.4970] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance Demonstrating that endothelial cell loss following Descemet stripping automated endothelial keratoplasty (DSAEK) is independent of donor cornea preservation time (PT) could increase the pool of corneal tissue available for keratoplasty. Objective To determine whether endothelial cell loss 3 years after successful DSAEK is related to PT. Design, Setting, and Participants A multicenter, double-masked, randomized clinical trial included 40 clinical sites (70 surgeons) in the United States, with donor corneas provided by 23 US eye banks. A total of 945 eyes of 769 participants were included in the Cornea Preservation Time Study that had not experienced graft failure 3 years after DSAEK, performed primarily for Fuchs endothelial corneal dystrophy (96% of the cohort). The study was conducted from April 16, 2012, to June 5, 2017. Interventions DSAEK with random assignment of a donor cornea with PT of 0 to 7 days (0-7d PT) or 8 to 14 days (8-14d PT). Main Outcomes and Measures Endothelial cell density (ECD) at 3 years determined by a central image analysis reading center from clinical specular or confocal central endothelial images. Results Nine hundred forty-five eyes of 769 participants (median age, 70 years [range, 42-90 years], 60.8% women, 93.0% white) in the Cornea Preservation Time Study that had not experienced graft failure 3 years after DSAEK were included. At the initial eye bank tissue screening, mean (SD) central ECD was 2746 (297) cells/mm2 in the 0-7d PT group (n = 485) and 2723 (284) cells/mm2 in the 8-14d PT group (n = 460). At 3 years, the mean (SD) ECD decreased from baseline by 37% (21%) in the 0-7d PT group and 40% (22%) in the 8-14d PT group to 1722 (626) cells/mm2 and 1642 (631) cells/mm2, respectively (mean difference, 73 cells/mm2; 95% CI, 8-138 cells/mm2; P = .03). When analyzed as a continuous variable (days), longer PT was associated with lower ECD (mean difference by days, 15 cells/mm2; 95% CI, 4-26 cells/mm2; P = .006). Endothelial cell loss (ECL) was comparable from 4 to 13 days’ PT (n = 878; 36%-43% when tabulated by day). Available extension study ECD results at 4 years mirrored those at 3 years in the 203 eyes in the 0-7d PT group (mean [SD] ECD, 1620 [673] cells/mm2 and mean [SD] ECL, 41% [23%]) and 209 eyes in the 8-14d PT group (mean [SD] ECD, 1537 [683] cells/mm2 and mean [SD] ECL, 44% [23%]) (mean difference, 112 cells/mm2; 95% CI, 5-219 cells/mm2; P = .04). Conclusions and Relevance Although ECL 3 years after Descemet stripping automated endothelial keratoplasty is greater with longer PT, the effect of PT on ECL is comparable from 4 to 13 days’ PT.
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Affiliation(s)
- Jonathan Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio,University Hospitals Cleveland Medical Center, Cleveland, Ohio,Cornea Image Analysis Reading Center, Cleveland, Ohio
| | - Beth Ann Benetz
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio,University Hospitals Cleveland Medical Center, Cleveland, Ohio,Cornea Image Analysis Reading Center, Cleveland, Ohio
| | | | - Loretta B Szczotka-Flynn
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio,University Hospitals Cleveland Medical Center, Cleveland, Ohio,Cornea Image Analysis Reading Center, Cleveland, Ohio
| | | | - Wendi Liang
- Jaeb Center for Health Research, Tampa, Florida
| | - Anthony J Aldave
- Stein Eye Institute, UCLA (University of California, Los Angeles)
| | | | | | | | | | - Sanjay V Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | - Robin L Gal
- Jaeb Center for Health Research, Tampa, Florida
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
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Patel SV, Lass JH, Benetz BA, Szczotka-Flynn LB, Cohen NJ, Ayala AR, Maguire MG, Drury DC, Dunn SP, Jeng BH, Jones MF, Menegay HJ, Oliva MS, Rosenwasser GOD, Seedor JA, Terry MA, Verdier DD. Postoperative Endothelial Cell Density Is Associated with Late Endothelial Graft Failure after Descemet Stripping Automated Endothelial Keratoplasty. Ophthalmology 2019; 126:1076-1083. [PMID: 30790587 DOI: 10.1016/j.ophtha.2019.02.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/17/2019] [Accepted: 02/11/2019] [Indexed: 01/21/2023] Open
Abstract
PURPOSE To determine whether preoperative endothelial cell density (ECD) and postoperative ECD after Descemet stripping automated endothelial keratoplasty (DSAEK) are associated with late endothelial graft failure (LEGF) in the Cornea Preservation Time Study (CPTS). DESIGN Cohort study within a multicenter, randomized clinical trial. PARTICIPANTS A total of 1007 individuals (1223 study eyes), mean age 70 years, undergoing DSAEK for Fuchs' dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (PACE) (6% of eyes) and followed for up to 5 years. METHODS Central ECD was determined by a central image analysis reading center. Preoperative ECD was determined for 1209 eyes that did not fail and 14 eyes that experienced LEGF. The ECD at 6 and 12 months after DSAEK, the change in ECD from preoperative to 6 and 12 months, surgeon-reported operative complications, and postoperative graft dislocation were investigated for an association with LEGFs unrelated to other postoperative events. Univariable and multivariable Cox proportional hazards regression models were used to assess associations. MAIN OUTCOME MEASURES Late endothelial graft failure and its associations with pre- and postoperative ECD and operative complications. RESULTS The cumulative probability of LEGF was 1.3% (95% confidence interval [CI], 0.8%-2.4%). Median (interquartile range [IQR]) preoperative ECDs were similar for eyes with LEGF (2523; 2367-3161) cells/mm2) and eyes without failure (2727; 2508-2973) cells/mm2) (P = 0.34). The ECD at 6 months was associated with LEGF (P < 0.001) in time-to-event analyses, whereas preoperative ECD was not (P = 0.55). The cumulative incidence (95% CI) of LEGF was 6.5% (3.0%, 14.0%) for 97 grafts with a 6-month ECD less than 1200 cells/mm2, 0.3% (0.0%, 2.4%) for 310 grafts with a 6-month ECD between 1200 and 2000 cells/mm2, and 0.6% (0.1%, 2.7%) for 589 grafts with a 6-month ECD greater than 2000 cells/mm2. In multivariable analyses, ECD at 6 months and operative complications were both associated with LEGF (P = 0.002 and P = 0.01, respectively), whereas graft dislocation was not (P = 0.61). CONCLUSIONS In eyes undergoing DSAEK, preoperative ECD is unrelated to LEGF, whereas lower ECD at 6 months is associated with LEGF. Early endothelial cell loss after DSAEK and intraoperative complications should be minimized to improve graft survival.
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Affiliation(s)
- Sanjay V Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Jonathan H Lass
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio.
| | - Beth Ann Benetz
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio
| | - Loretta B Szczotka-Flynn
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio
| | | | | | - Maureen G Maguire
- Center for Preventive Ophthalmology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Steven P Dunn
- Michigan Cornea Consultants, P.C., Southfield, Michigan
| | - Bennie H Jeng
- University of California-San Francisco, San Francisco, California (now the University of Maryland, Baltimore, Maryland)
| | | | - Harry J Menegay
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio
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12
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Lass JH, Benetz BA, Patel SV, Szczotka-Flynn LB, O’Brien R, Ayala AR, Maguire MG, Daoud YJ, Greiner MA, Hannush SB, Lee WB, Mauger TF, Menegay HJ, Mifflin MD, Raizman MB, Rose-Nussbaumer J, Schultze RL, Schmidt GA, Sugar A, Terry MA, Verdier DD. Donor, Recipient, and Operative Factors Associated With Increased Endothelial Cell Loss in the Cornea Preservation Time Study. JAMA Ophthalmol 2019; 137:185-193. [PMID: 30422157 PMCID: PMC6439830 DOI: 10.1001/jamaophthalmol.2018.5669] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/26/2018] [Indexed: 12/19/2022]
Abstract
Importance Determining factors associated with endothelial cell loss after Descemet stripping automated endothelial keratoplasty (DSAEK) could improve long-term graft survival. Objective To evaluate the associations of donor, recipient, and operative factors with endothelial cell density (ECD) 3 years after DSAEK in the Cornea Preservation Time Study. Design, Setting, and Participants This cohort study was a secondary analysis of data collected in a multicenter, double-masked, randomized clinical trial. Forty US clinical sites with 70 surgeons participated, with donor corneas provided by 23 US eye banks. Individuals undergoing DSAEK for Fuchs dystrophy or pseudophakic/aphakic corneal edema were included. Interventions The DSAEK procedure, with random assignment of a donor cornea with a preservation time of 0 to 7 days or 8 to 14 days. Main Outcomes and Measures Endothelial cell density at 3 years as determined by a reading center from eye bank and clinical specular or confocal central endothelial images. Results The study included 1090 participants (median age, 70 years) with 1330 affected eyes (240 bilateral cases [22.0%]), who underwent DSAEK for Fuchs dystrophy (1255 eyes [94.4%]) or pseudophakic/aphakic corneal edema (PACE) (75 eyes [5.6%]). Of these, 801 eyes (60.2%) belonged to women and 1207 (90.8%) to white individuals. A total of 749 participants (913 eyes; 164 [21.9%] bilateral cases) had functioning grafts with acceptable endothelial images preoperatively and at 3 years postoperatively and were included in this analysis. Factors associated with a lower ECD at 3 years (estimated effect with 99% CI) in the final multivariable model included donors with diabetes (-103 [-196 to -9] cells/mm2), lower screening ECD (-234 [-331 to -137] per 500 cells/mm2), recipient diagnosis of PACE (-257 [-483 to -31] in cells/mm2), and operative complications (-324 [-516 to -133] in cells/mm2). Endothelial cell loss (ECL) from a preoperative measurement to a 3-year postoperative measurement was 47% (99% CI, 42%-52%) for participants receiving tissue from donors with diabetes vs 43% (99% CI, 39%-48%) without diabetes; it was 53% (99% CI, 44%-62%) for participants diagnosed with PACE vs 44% (99% CI, 39%-49%) for those diagnosed with Fuchs dystrophy, and 55% (99% CI, 48%-63%) in participants who experienced operative complications vs 44% (99% CI, 39%-48%) in those who did not. No other donor, recipient, or operative factors were significantly associated with 3-year ECD. Conclusions and Relevance Donor diabetes, lower screening ECD, a PACE diagnosis in the recipient, and operative complications were associated with lower ECD at 3 years after DSAEK surgery and may be associated with long-term graft success. While causation cannot be inferred, further studies on the association of donor diabetes and PACE in recipients with lower 3-year ECD warrant further study.
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Affiliation(s)
- Jonathan H. Lass
- Cornea Image Analysis Reading Center, Department of Ophthalmology and Visual Sciences, University Hospitals Eye Institute, Case Western Reserve University, Cleveland, Ohio
| | - Beth Ann Benetz
- Cornea Image Analysis Reading Center, Department of Ophthalmology and Visual Sciences, University Hospitals Eye Institute, Case Western Reserve University, Cleveland, Ohio
| | - Sanjay V. Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Loretta B. Szczotka-Flynn
- Cornea Image Analysis Reading Center, Department of Ophthalmology and Visual Sciences, University Hospitals Eye Institute, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Maureen G. Maguire
- Center for Preventive Ophthalmology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yassine J. Daoud
- The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Thomas F. Mauger
- The Ohio State University Wexner Medical Center-Havener Eye Institute, Columbus
| | - Harry J. Menegay
- Cornea Image Analysis Reading Center, Department of Ophthalmology and Visual Sciences, University Hospitals Eye Institute, Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | - Alan Sugar
- Kellogg Eye Center, University of Michigan, Ann Arbor
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13
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Stulting RD, Lass JH, Terry MA, Benetz BA, Cohen NJ, Ayala AR, Maguire MG, Croasdale C, Daoud YJ, Dunn SP, Goins KM, Gupta PC, Macsai MS, Mian SI, Pramanik S, Rose-Nussbaumer J, Song JC, Stark WJ, Sugar A, Verdier DD, Szczotka-Flynn LB. Factors Associated With Graft Rejection in the Cornea Preservation Time Study. Am J Ophthalmol 2018; 196:197-207. [PMID: 30308200 DOI: 10.1016/j.ajo.2018.10.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/25/2018] [Accepted: 10/02/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE To identify factors related to graft rejection following Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN Cohort study within a multicenter randomized clinical trial. METHODS A total of 1330 eyes of 1090 subjects undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0-7 days (n = 675) or 8-14 days (n = 655) and followed for 3 years. Central endothelial cell density (ECD) was determined by a central image analysis reading center. Multivariable Cox models adjusted for PT, recipient diagnosis, and surgeon effect were used to identify factors associated with rejection. RESULTS Cumulative probability of definite graft rejection was 3.6% (99% confidence interval 2.5%-5.3%). Younger recipient age was associated with graft rejection (P < .001; hazard ratio: 0.53 [0.33, 0.83] per decade). PT, donor-recipient sex mismatch, recipient diagnosis, recipient race, graft size, discontinuation of topical corticosteroids and immune-modulators, prior immunizations within 3 months, and prior glaucoma surgery were not associated with rejection (P > .01). Among clear grafts with an ECD measurement at baseline and 3 years (n = 913), endothelial cell loss (ECL) was greater in eyes that experienced a rejection episode (n = 27) than in those that did not (n = 886) (48% vs 38%, P = .03). Twelve of 44 eyes (27%) with definite graft rejection subsequently failed, comprising 15% of the 79 failures in the CPTS. CONCLUSIONS Graft rejection is uncommon after DSAEK and more likely with younger age, in a study cohort mostly > 50 years old. Rejection increases ECL, but it is not a leading cause of DSAEK failure.
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Affiliation(s)
| | - Jonathan H Lass
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio, USA.
| | | | - Beth Ann Benetz
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio, USA
| | | | | | - Maureen G Maguire
- Center for Preventive Ophthalmology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Yassine J Daoud
- The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Steven P Dunn
- Michigan Cornea Consultants, P.C., Southfield, Michigan, USA
| | - Kenneth M Goins
- University of Iowa Department of Ophthalmology and Visual Sciences, Iowa City, Iowa, USA
| | - Pankaj C Gupta
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio, USA
| | - Marian S Macsai
- Northshore University Health System, Glenview, Illinois, USA
| | - Shahzad I Mian
- Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jennifer Rose-Nussbaumer
- University of California - San Francisco, and Francis I Proctor Foundation, San Francisco, California, USA
| | - Jonathan C Song
- University of Southern California Roski Eye Institute, Los Angeles, California, USA
| | - Walter J Stark
- The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alan Sugar
- Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Loretta B Szczotka-Flynn
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, Ohio, USA
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14
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Terry MA, Aldave AJ, Szczotka-Flynn LB, Liang W, Ayala AR, Maguire MG, Croasdale C, Daoud YJ, Dunn SP, Hoover CK, Macsai MS, Mauger TF, Pramanik S, Rosenwasser GOD, Rose-Nussbaumer J, Stulting RD, Sugar A, Tu EY, Verdier DD, Yoo SH, Lass JH. Donor, Recipient, and Operative Factors Associated with Graft Success in the Cornea Preservation Time Study. Ophthalmology 2018; 125:1700-1709. [PMID: 30098353 PMCID: PMC6196643 DOI: 10.1016/j.ophtha.2018.08.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 07/27/2018] [Accepted: 08/03/2018] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To associate donor, recipient, and operative factors with graft success 3 years after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN Cohort study within a multicenter, double-masked, randomized clinical trial. PARTICIPANTS One thousand ninety individuals (1330 study eyes) with a median age of 70 years undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (PACE; 6% of eyes). METHODS Eyes undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0 to 7 days (n = 675) or 8 to 14 days (n = 655). Donor, recipient, and operative parameters were recorded prospectively. Graft failure was defined as regraft for any reason, a graft that failed to clear by 8 weeks after surgery, or an initially clear graft that became and remained cloudy for 90 days. Failure in the first 8 weeks was classified further as primary donor failure or early failure, in the absence or presence of operative complications, respectively. Proportional hazards and logistic regression models were used to estimate risk ratios (RR) and 99% confidence intervals (CIs) for graft failure. MAIN OUTCOME MEASURES Graft success at 3 years. RESULTS One thousand two hundred fifty-one of 1330 grafts (94%) remained clear at 3 years and were considered successful. After adjusting for PT, tissue from donors with diabetes (RR, 2.35; 99% CI, 1.03-5.33) and operative complications (RR, 4.21; 99% CI, 1.42-12.47) were associated with increased risk for primary or early failure. Preoperative diagnosis of PACE (RR, 3.59; 99% CI, 1.05-12.24) was associated with increased risk for late failure by 3 years after surgery compared with Fuchs dystrophy. Graft success showed little variation among other factors evaluated, including donor age (RR, 1.19 per decade; 99% CI, 0.91-1.56 per decade), preoperative donor endothelial cell density (RR, 1.10 per 500 cells; 99% CI, 0.74-1.63 per 500 cells), graft diameter (RR, 1.22 per 1 mm; 99% CI, 0.39-3.76 per 1 mm), and injector use for graft insertion (RR, 0.92; 99% CI, 0.40-2.10). CONCLUSIONS Descemet stripping automated endothelial keratoplasty success in the early and entire postoperative period is more likely when the donor did not have diabetes and was without operative complications and in the long-term postoperative period in recipients with Fuchs dystrophy compared with those with PACE. Mechanisms whereby diabetic donors and PACE recipients reduce the rate of graft success after DSAEK warrant further study.
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Affiliation(s)
| | - Anthony J Aldave
- Stein Eye Institute, University of California, Los Angeles, Los Angeles, California
| | - Loretta B Szczotka-Flynn
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, Ohio
| | - Wendi Liang
- Jaeb Center for Health Research, Tampa, Florida
| | | | - Maureen G Maguire
- Center for Preventive Ophthalmology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Yassine J Daoud
- The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Steven P Dunn
- Michigan Cornea Consultants, PC, Southfield, Michigan
| | | | | | - Thomas F Mauger
- The Ohio State University Wexner Medical Center, Havener Eye Institute, Columbus, Ohio
| | | | | | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California
| | | | - Alan Sugar
- University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan
| | - Elmer Y Tu
- University of Illinois Chicago Eye and Ear Infirmary, Chicago, Illinois
| | | | - Sonia H Yoo
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Jonathan H Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, Ohio.
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15
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Mian SI, Aldave AJ, Tu EY, Ayres BD, Jeng BH, Macsai MS, Nordlund ML, Penta JG, Pramanik S, Szczotka-Flynn LB, Ayala AR, Liang W, Maguire MG, Lass JH. Incidence and Outcomes of Positive Donor Rim Cultures and Infections in the Cornea Preservation Time Study. Cornea 2018; 37:1102-1109. [PMID: 29912040 PMCID: PMC6081243 DOI: 10.1097/ico.0000000000001654] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess donor rim culture results and outcomes of ocular infections in the Cornea Preservation Time Study (CPTS). METHODS Donor corneal rim cultures were optional. Donor characteristics were assessed for association with positive cultures using the Fisher exact test and Poisson regression analyses. Incidence rates of ocular infections were estimated, and 95% confidence intervals were calculated. RESULTS Cultures were performed in 784 (58.9%) of the 1330 cases. For the 0 to 7-day versus 8 to 14-day preservation time groups, respectively, positive fungal growth occurred in 10 of 397 (2.5%) versus 5 of 387 (1.3%) corneas (P = 0.30), whereas positive bacterial cultures occurred in 6 of 397 (1.5%) versus 4 of 387 (1.0%) corneas (P = 0.75). Surgeon-prepared tissue remained a significant risk for positive fungal cultures [relative risk (RR) of surgeon- versus eye-bank-prepared, 2.85; 95% CI (1.02-7.98)], whereas younger donors [RR per year of age, 0.96; 95% CI (0.93-1.00)] and accidental death donors [RR of accident versus disease, 3.71; 95% CI (1.36-10.13)] were at a greater risk for positive bacterial cultures. Fungal infection (Candida glabrata) developed in 1 (6.7%) of 15 recipients with a positive fungal culture, and no recipient infections occurred with positive bacterial culture. With one additional fungal keratitis (Candida albicans) and one bacterial endophthalmitis (E. coli) with no rim culture performed, a total of 2 of 1330 eyes (0.15%) developed fungal and 1/1330 eyes (0.08%) developed bacterial postkeratoplasty infections. CONCLUSIONS A longer preservation time was not associated with a higher rate of positive donor rim cultures. The overall rate of infection across the entire cohort was low.
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Affiliation(s)
| | - Anthony J. Aldave
- Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA
| | - Elmer Y. Tu
- University of Illinois Chicago Eye and Ear Infirmary, Chicago, IL
| | | | - Bennie H. Jeng
- University of California, San Francisco, San Francisco, CA (now at the University of Maryland, Baltimore, MD)
| | | | | | | | | | - Loretta B. Szczotka-Flynn
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, OH
| | | | | | - Maureen G. Maguire
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA
| | - Jonathan H. Lass
- Case Western Reserve University Department of Ophthalmology and Visual Sciences and University Hospitals Eye Institute, Cleveland, OH
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Abstract
BACKGROUND Dry eye disease is a common chronic condition that is characterized by ocular discomfort and visual disturbances that decrease quality of life. Many clinicians recommend the use of supplements of n-3 fatty acids (often called omega-3 fatty acids) to relieve symptoms. METHODS In a multicenter, double-blind clinical trial, we randomly assigned patients with moderate-to-severe dry eye disease to receive a daily oral dose of 3000 mg of fish-derived n-3 eicosapentaenoic and docosahexaenoic acids (active supplement group) or an olive oil placebo (placebo group). The primary outcome was the mean change from baseline in the score on the Ocular Surface Disease Index (OSDI; scores range from 0 to 100, with higher scores indicating greater symptom severity), which was based on the mean of scores obtained at 6 and 12 months. Secondary outcomes included mean changes per eye in the conjunctival staining score (ranging from 0 to 6) and the corneal staining score (ranging from 0 to 15), with higher scores indicating more severe damage to the ocular surface, as well as mean changes in the tear break-up time (seconds between a blink and gaps in the tear film) and the result on Schirmer's test (length of wetting of paper strips placed on the lower eyelid), with lower values indicating more severe signs. RESULTS A total of 349 patients were assigned to the active supplement group and 186 to the placebo group; the primary analysis included 329 and 170 patients, respectively. The mean change in the OSDI score was not significantly different between the active supplement group and the placebo group (-13.9 points and -12.5 points, respectively; mean difference in change after imputation of missing data, -1.9 points; 95% confidence interval [CI], -5.0 to 1.1; P=0.21). This result was consistent across prespecified subgroups. There were no significant differences between the active supplement group and the placebo group in mean changes from baseline in the conjunctival staining score (mean difference in change, 0.0 points; 95% CI, -0.2 to 0.1), corneal staining score (0.1 point; 95% CI, -0.2 to 0.4), tear break-up time (0.2 seconds; 95% CI, -0.1 to 0.5), and result on Schirmer's test (0.0 mm; 95% CI, -0.8 to 0.9). At 12 months, the rate of adherence to treatment in the active supplement group was 85.2%, according to the level of n-3 fatty acids in red cells. Rates of adverse events were similar in the two trial groups. CONCLUSIONS Among patients with dry eye disease, those who were randomly assigned to receive supplements containing 3000 mg of n-3 fatty acids for 12 months did not have significantly better outcomes than those who were assigned to receive placebo. (Funded by the National Eye Institute, National Institutes of Health; DREAM ClinicalTrials.gov number, NCT02128763 .).
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Affiliation(s)
- Penny A Asbell
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York
| | - Maureen G Maguire
- Department of Ophthalmology, University of Pennsylvania, Philadelphia
| | - Maxwell Pistilli
- Department of Ophthalmology, University of Pennsylvania, Philadelphia
| | - Gui-shuang Ying
- Department of Ophthalmology, University of Pennsylvania, Philadelphia
| | | | | | - Meng C Lin
- School of Optometry, University of California, Berkeley, Berkeley
| | - Roni M Shtein
- Department of Ophthalmology, University of Michigan, Ann Arbor
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Lass JH, Szczotka-Flynn LB, Ayala AR, Benetz BA, Gal RL, Aldave AJ, Corrigan MM, Dunn SP, McCall TL, Pramanik S, Rosenwasser GO, Ross KW, Terry MA, Verdier DD. Cornea preservation time study: methods and potential impact on the cornea donor pool in the United States. Cornea 2015; 34:601-8. [PMID: 25850706 PMCID: PMC4426012 DOI: 10.1097/ico.0000000000000417] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/14/2015] [Accepted: 01/28/2015] [Indexed: 01/27/2023]
Abstract
PURPOSE The aim of this study was to describe the aims, methods, donor and recipient cohort characteristics, and potential impact of the Cornea Preservation Time Study (CPTS). METHODS The CPTS is a randomized clinical trial conducted at 40 clinical sites (70 surgeons) designed to assess the effect of donor cornea preservation time (PT) on graft survival 3 years after Descemet stripping automated endothelial keratoplasty (DSAEK). Eyes undergoing surgery for Fuchs endothelial corneal dystrophy or pseudophakic/aphakic corneal edema were randomized to receive donor corneas stored ≤7 days or 8 to 14 days. Donor and patient characteristics, tissue preparation and surgical parameters, recipient and donor corneal stroma clarity, central corneal thickness, intraocular pressure, complications, and a reading center-determined central endothelial cell density were collected. Surveys were conducted to evaluate pre-CPTS PT practices. RESULTS The 1330 CPTS donors were: 49% >60 years old, 27% diabetic, had a median eye bank-determined screening endothelial cell density of 2688 cells/mm, and 74% eye bank prepared for DSAEK. A total of 1090 recipients (1330 eyes including 240 bilateral cases) had: median age of 70 years, were 60% female, 90% white, 18% diabetic, 52% phakic, and 94% had Fuchs endothelial corneal dystrophy. Before the CPTS, 19 eye banks provided PT data on 20,852 corneas domestically placed for DSAEK in 2010 to 2011; 96% were preserved ≤7 days. Of 305 American Academy of Ophthalmology members responding to a pre-CPTS survey, 233 (76%) set their maximum PT preference at 8 days or less. CONCLUSIONS The CPTS will increase understanding of factors related to DSAEK success and, if noninferiority of longer PT is shown, will have great potential to extend the available pool of endothelial keratoplasty donors.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01537393.
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Affiliation(s)
- Jonathan H. Lass
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, OH
| | - Loretta B. Szczotka-Flynn
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, OH
| | | | - Beth A. Benetz
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, OH
| | | | - Anthony J. Aldave
- Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA
| | | | | | | | | | | | | | | | | | - Writing Committee for the Cornea Preservation Time Study Group
- Department of Ophthalmology and Visual Sciences, Case Western Reserve University and University Hospitals Eye Institute, Cleveland, OH
- Jaeb Center for Health Research, Tampa, FL
- Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA
- Eye Associates Northwest, Seattle, WA
- Michigan Cornea Consultants, PC, Southfield, MI
- Cornea Associates of Texas, Dallas, TX
- Mid Atlantic Cornea Consultants, Baltimore, MD
- Central Pennsylvania Eye Center, Hershey, PA
- Midwest Eye-Banks, Ann Arbor, MI
- Devers Eye Institute, Portland, OR; and
- Verdier Eye Center, Grand Rapids, MI
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Jiang Y, Jacobs M, Bajaksouzian S, Foster AN, Debanne SM, Bielefeld R, Garvey M, Raghupathy S, Kern J, Szczotka-Flynn LB. Risk Factors for Microbial Bioburden During Daily Wear of Silicone Hydrogel Contact Lenses. Eye Contact Lens 2014; 40:148-56. [DOI: 10.1097/icl.0000000000000026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McMahon TT, Anderson RJ, Roberts C, Mahmoud AM, Szczotka-Flynn LB, Raasch TW, Friedman NE, Davis LJ. Repeatability of Corneal Topography Measurement in Keratoconus with the TMS-1. Optom Vis Sci 2005; 82:405-15. [PMID: 15894916 DOI: 10.1097/01.opx.0000162667.22303.76] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The purpose of this study was to report the test-retest variability of simulated indices derived from the TMS-1 topography instrument (Tomey Technology, Waltham, MA) in keratoconus subjects enrolled in the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study. METHODS Four images were taken at an initial visit and at a repeat visit several weeks later. From these images, 17 indices were simulated from published formulas. Mixed-model analysis was used on test-retest data from the TMS-1 videokeratography instrument during the baseline year. This analysis yields estimates of within- and between-visit variability. RESULTS Repeatability analysis revealed that within-visit standard errors were 1.0 to 5.9 times greater in keratoconus eyes than in normal controls when two images were analyzed from each visit. These values changed only slightly when more images were used. The ratio of between-visit standard errors of the indices were nearly equally greater than normal controls for (0.9-4.6 and 0.9-4.3) two images per eye and all images per eye, respectively. CONCLUSIONS These results suggest that the repeatability of simulated indices derived from TMS-1 topography in keratoconus subjects is poorer than in normal controls.
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Affiliation(s)
- Timothy T McMahon
- Department of Ophthalmology & Visual Sciences, University of Illinois College of Medicine at Chicago, Chicago, Illinois 60612, USA.
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