Topical corticosteroids with topical cyclosporine A versus topical corticosteroids alone for immunological corneal graft rejection

PURPOSE

To assess the efficacy and safety of supplementing topical cyclosporine A (CsA) to topical corticosteroids (CS), in the prophylaxis and treatment of corneal graft rejection following penetrating keratoplasty (PK).

METHODS

Meta-analysis. Search was performed in PubMed, CENTRAL, ClinicalTrials.gov, reference lists of articles and conference proceedings. Primary outcomes: 1-year rejection-free survival rate (prophylaxis); resolution rate of rejection episodes (treatment). Secondary outcomes: 6- and 24-month rejection-free graft survival rate, number of rejection episodes during follow-up, time-to-resolution of rejection episode, 12- and 24-months graft survival rate, adverse events. Subgroup analyses were planned for high-risk grafts; primary vs. secondary prophylaxis of graft rejection episodes; and CsA concentrations of 0.05%, 1%, and 2%.

RESULTS

Five studies of moderate methodological quality were included (one retrospective, four RCT), assessing 459 eyes (CS + CsA 226, CS 233). In the prophylaxis setting, supplemental CsA was associated with a higher rejection-free survival rate at 12-months (RR 1.25, 95% CI: 1.00-1.56, p = 0.05) and 24-months post-PK (RR 1.56, 95% CI: 1.15-2.11, p < 0.01), though no differences were found at the 6-months timepoint (p = 0.93). This effect was mostly verified using CsA 2% in the high-risk subset of patients. In the treatment setting, no differences were found in the resolution rate of rejection episodes (p = 0.23). No differences existed on drug-related adverse events.

CONCLUSION

In the prophylaxis of rejection episodes post-PK, the combined regimen of CS + CsA was associated with a higher 1- and 2-year rejection-free graft survival rate. Subgroup analysis mostly supported the use of CsA 2% for high-risk grafts. Further studies are needed to validate these results.

Characterization of posterior corneal astigmatism in a population with keratoconus

Background: The curvature of the anterior corneal surface is traditionally used as a surrogate to estimate corneal astigmatism. In recent years, increasing importance has been attributed to posterior corneal astigmatism as an indicator. Our aim is to characterize the posterior corneal surface in a population with keratoconus and investigate its predictive value to keratoconus progression. Methods: Retrospective study from a tertiary care centre (Hospital de Santa Maria, Lisbon, Portugal). Eighty-five patients (85 eyes) with keratoconus were included. All patients had two tomographical examinations ≥12 months apart (Pentacam HR). Vector analysis was used to calculate anterior (ACA), posterior (PCA), and total corneal astigmatism (TCA). Multivariate logistic regression was used to assess the predictive value of PCA to keratoconus progression, adjusting for ACA, TCA and several tomographical indices. Results: Study participants had a mean age of 32 (SD = 12.5) years. Mean tomographical keratoconus classification was 2.16 (SD = 0.95), with a mean Kmax of 55.8D (SD = 7.8). Mean power of PCA, ACA and TCA was, respectively, -0.88D (SD = 0.84), 3.74D (SD = 2.36), and 3.06D (SD = 2.01) and its centroids were 0.44D x 15º, 1.65D x 112º, and 1.61D x 106º, respectively. The power of PCA was ≥0.50, 1.00 and 2.00D in 75.3%, 32.9%, and 3.5% of patients, respectively, inducing against-the-rule astigmatism in 60.0% of patients. On average, ACA overestimated TCA in 0.35D x 151º (p < .01). ACA and TCA were highly correlated but showed a lack of agreement for clinical purposes. A predictive role for PCA was excluded. Conclusions: In this population with keratoconus, PCA contributed substantially to TCA. However, PCA was not a valuable predictor for disease progression.

DMEK versus DSAEK for Fuchs’ endothelial dystrophy: A meta-analysis

Purpose:

To compare the safety and efficacy profiles of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in adult patients with Fuchs’ endothelial dystrophy.

Methods:

Electronic database search on MEDLINE and CENTRAL from inception to August 2017. We included all comparative studies of DMEK versus DSAEK in patients with diagnosed Fuchs’ endothelial dystrophy. Studies assessing rescue procedures were excluded to minimize bias. Primary outcome: mean difference in best-corrected visual acuity (BCVA) at 3, 6, and 12 months postoperatively. Secondary outcomes: rates of graft primary failure, rejection, and rebubbling; other graft-related issues; mean difference in endothelial cell density; subjective visual outcomes; and patient satisfaction.

Results:

A total of 10 retrospective studies of moderate methodological quality were included (n = 947 eyes, 646 DMEK). BCVA was better with DMEK at all evaluated time points (0.16 logMAR at 12 months) comparing to DSAEK (0.30 logMAR; p < 0.001). DMEK had a 60% lower rate of rejection (risk ratio (RR) 0.4, 95% CI (0.24, 0.67), p = 0.0005), but required more rebubblings (RR = 2.48, 95% CI (1.32, 4.64), p = 0.005). DMEK had more primary graft failures and less endothelial cell density loss, but statistical difference was not reached. More patients were satisfied after DMEK (odds ratio = 10.29, 95% CI (3.55, 29.80), p < 0.0001).

Conclusion:

DMEK showed better postoperative results regarding BCVA, patient satisfaction, and graft-related issues. However, the small number of studies with short follow-up times and other methodological issues prompt us to interpret these results carefully.