Aqueous humor total protein levels predict 6-year graft survival after endothelial keratoplasty in surgically treated glaucoma eyes

The purpose of this study is to evaluate long-term outcomes of endothelial keratoplasty (EK) compared with penetrating keratoplasty (PK) for corneal endothelial dysfunction [Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK)]. In this systematic review, we searched PubMed, the Cochrane Library, and Embase up to May 2022 and considered all types of studies addressing our objective. Graft survival at 5, 10, and 15 years was the main outcome. Fifty cohort studies were included. At 5 years, in FECD and BK, graft survival seemed higher after EK than PK. Two comparative studies showed either a higher 5-year graft survival after EK than PK or no significant differences. Including noncomparative studies, in FECD, the 5-year graft survival ranged from 0.69 to 0.98 for PK, from 0.93 to 1.00 for DSEK, and from 0.93 to 0.99 for Descemet membrane endothelial keratoplasty (DMEK). In BK, the 5-year graft survival ranged from 0.39 to 0.91 for PK, from 0.65 to 0.89 for DSEK, and from 0.84 to 0.95 for DMEK. The 10-year graft survival ranged from 0.20 to 0.90 for PK and from 0.62 to 0.92 for EK. The mean 5-year best spectacle-corrected visual acuity ranged from 0.73 to 0.43 LogMAR for PK, from 0.61 to 0.09 for DSEK, and from 0.31 to 0.05 for DMEK. The 5-year rejection rate ranged from 11.0% to 28.7% for PK, from 5.0% to 7.9% for DSEK, and from 1.7% to 2.6% for DMEK. These results suggest a higher 5-year graft survival and better secondary outcomes after EK. Nevertheless, the level of evidence was low. CRD42021260614.

Changing Practice Patterns and Long-term Outcomes of Endothelial Versus Penetrating Keratoplasty: A Prospective Dutch Registry Study

Purpose:To report the outcomes of corneal transplantation utilizing corneas retrieved from donors with chronic kidney disease (CKD).Methods:Outcomes of corneal transplantation (optical PK and EK) performed from Jan 2018 to Dec 2018 utilizing donor corneas retrieved from CKD patients was performed retrospectively.Results:Of the total of 233 donor corneas retrieved from CKD, 135 (57.9%) were utilized for transplantation after the routine screening protocol of the eye bank. Mean age of the donors was 56.2 ± 13.5 years. The mean endothelial cell density on specular microscopy of the donor corneas used for optical PK was 2685.7 ± 377.6 cells/mm2 (range, 2028–3448 cells/mm2) and for EK was 2731.7 ± 189.1 cells/mm2 (range, 2380–3194 cells/mm2). The overall primary graft failure rate was 5.1%. All grafts except 1, cleared in the PK group. In the EK group (6 DMEK and 16 DSAEK), 1 patient had a complete graft detachment and another 1 had a primary graft failure after DMEK.Conclusion:The donor corneas retrieved from chronic kidney disease patients are safe and suitable for optical keratoplasty provided they meet the criteria for transplantation.

BackgroundTo report iridoschisis in patients with atopic dermatitis and the outcome of repeat corneal transplantations for intractable bullous keratopathy.Case presentationThree patients with atopic dermatitis, iridoschisis and bullous keratopathy, underwent numerous corneal transplantation procedures including penetrating keratoplasty (PKP), and endothelial keratoplasty (EK), which failed within a short period due to rapid corneal endothelial cell (CEnC) loss without graft rejection. Aqueous humor total protein levels were overwhelmingly higher in all patients. Case 1: A 26-year-old man with atopic dermatitis had iridoschisis and bullous keratopathy in the left eye. During the 10-year follow-up, he underwent seven corneal transplantations (four EK, and three PKP). However, all grafts failed because of rapid CEnC loss without graft rejection. Case 2: A 53-year-old man with severe atopic dermatitis had iridoschisis and bullous keratopathy in the right eye. He underwent three corneal transplantations (one EK, followed by two PKP) over five years. All grafts failed within short periods due to rapid CEnC loss and endothelial decompensation without graft rejection. Case 3: A 54-year-old man with severe atopic dermatitis had iridoschisis and bullous keratopathy in the right eye. He underwent three EK within short periods due to rapid CEnC loss.ConclusionsWe hereby report the association of iridoschisis with bullous keratopathy in atopic dermatitis for the first time in the literature. Clinicians should be aware that the prognosis of corneal transplants in such patients appears to be poor necessitating repeat procedures.

318 consecutive DSEK (n=189) and DMEK (n=129) grafts of 223 patients performed by 8 surgeons with standardised protocols between January 2006 and October 2021 were analysed. Group differences were compared with parametric and non-parametric tests. Kaplan-Meier analysis and Cox regression were conducted for graft survival and identify graft failure and rejection risk factors. At 5 years, graft survival was 97% and 98% (p=0.370) in DSEK and DMEK eyes. Mean percentage endothelial cell loss was 56.6±17.6 in DSEK and 55.6±15.2 in DMEK eyes (p=0.865). Mean BSCVA was 0.12±0.13 LogMAR in DSEK and 0.00±0.17 in DMEK grafts (p<0.00001) at 5 years postop. Within 5 years, 12% of DSEK and 9% of DMEK eyes developed allograft rejection (p=0.412). Rebubbling was performed in 9.0% of DSEK and 2.3% of DMEK grafts (p=0.211). Cox regression identified rejection episode (HR 1.36; 95% CI: 2.31-80.22 (p=0.004)) as a significant contributing factor for graft failure. At 5 years there was no significant difference in graft survival or endothelial cell loss between DMEK and DSEK eyes with FED. We propose that our standardised technique reduces the need for rebubbling. DMEK had superior visual acuity outcomes compared with DSEK in these patients up to 5 years after surgery.

Five-Year Graft Survival Comparing Descemet Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty

The rapid growth of endothelial keratoplasty as the treatment of choice for FED is based upon the belief that visual recovery is more rapid, surgically induced astigmatism (regular and irregular) is less and rates of transplant rejection are lower with EK. This change in practice also assumes that the rates of long term transplant survival are equal for the two procedures. The practical differences between the surgical procedures mean that visual recovery is inherently more rapid following EK, but this review found no strong evidence from RCTs of any difference in the final visual outcome between EK and PKP for people with FED. This review also found that higher order aberrations are fewer following EK but endothelial cell loss is greater following EK. The RCTs that we included employed different EK techniques, which may have a bearing on these findings. EK procedures have evolved over the years and can be performed using different techniques, for example deep lamellar endothelial keratoplasty, Descemets stripping endothelial keratoplasty (DSEK), Descemets stripping automated endothelial keratoplasty (DSAEK), femtosecond laser-assisted endothelial keratoplasty and Descemet membrane endothelial keratoplasty (DMEK). More RCTs are needed to compare PKP with commonly performed EK procedures such as DSEK, DSAEK and DMEK in order to determine the answers to two key questions, whether there is any difference in the final visual outcome between these techniques and whether there are differences in the rates of graft survival in the long term?

To compare the survival of a first penetrating keratoplasty (PK) or endothelial keratoplasty (EK) for iridocorneal endothelial (ICE) syndrome with transplant survival in Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK). We compared graft survival of PK and EK for ICE syndrome for 2 time periods. We then compared graft survival in ICE syndrome with graft survival in FED and PBK. Kaplan-Meier estimates of graft survival up to 5 years posttransplant were calculated with 95% confidence intervals (CI), whereas comparisons between the groups were performed using the log-rank test. We included 86 first transplants for ICE syndrome. There was no difference in graft survival between the 58 PKs and the 28 EKs for up to 5 years after surgery (P = 0.717). For the period from 2009 to 2017, the 5-year graft survival rates for ICE syndrome were 64.3% (CI, 21.8%-88.0%) for the 16 PKs and 66.8% (CI, 41.8%-83.0%) for the 26 EKs (P = 0.469). Between 2009 and 2017, the 5-year survival rate for 42 grafts with ICE syndrome was 62.7% (CI, 39.6%-79.0%), which was lower than 75.9% (CI, 74.2%-77.4%) in 7058 transplants for FED but higher than 55.1% (CI, 52.0%-58.0%) in 3320 transplants for PBK, although the numbers of ICE transplants are too small to tell whether this difference was by chance. The results indicate no difference in graft survival between PK and EK for ICE syndrome. Graft survival in ICE syndrome is intermediate between that of FED and PBK.

Précipités rétro-cornéens annulaires

Transplant Rejection Following Endothelial Keratoplasty and Penetrating Keratoplasty in the United Kingdom: Incidence and Survival

An increasing proportion of corneal transplant procedures are undertaken for replacement of a failed previous graft. The proportion of lamellar transplant procedures has significantly increased. There are limited large-scale reports on regraft procedures that may help guide surgeons and patients in their choice of surgery. To examine the corneal transplant replacement survival rates for the 3 main indications and types of regraft surgery. This national transplant registry study examined surgery and follow-up data on all corneal transplants performed in the United Kingdom from April 1, 1999, through March 31, 2016. Actuarial regraft 5-year survival rates were compared for the 3 main indications and types of graft: penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty for keratoconus, PK and endothelial keratoplasty (EK) for Fuchs endothelial dystrophy (FED), and pseudophakic bullous keratopathy (PBK). A total of 9925 regrafts were analyzed during the 17-year study period. Penetrating keratoplasty represented 7261 cases (73.2%) in the cohort. Endothelial keratoplasty increased by 1361.5%, from 12 (2.6%; 95% CI, 1.3%-4.5%) of all 467 regrafts during 2005-2006 to 292 (38.0%; 95% CI, 34.6%-41.6%) of 768 during 2015-2016. The median time to first regraft for all graft types was 28 months (interquartile range, 10-64 months). When examining all graft types performed for all indications, stratification of 5-year survival was found for successive grafts, with a difference in survival of 25 270 (72.5%; 95% CI, 71.7%-73.2%) from the first graft to 4224 (53.4%; 95% CI, 51.4%-55.4%) from the second graft and 1088 (37.3%; 95% CI, 33.4%-41.3%) from the second to third graft. For first regrafts in keratoconus and PBK, survival after lamellar and PK procedures was similar. For FED, there was a higher regraft survival after PK (375 [70.8%]; 95% CI, 64.6%-76.1%) compared with EK (303 [54.7%]; 95% CI, 45.8%-62.8%) (P < .001). For FED and PBK, there was no difference in first regraft survival identified between EK followed by PK vs PK followed by PK or EK followed by EK vs PK followed by EK. In this large registry-based analysis of corneal regraft survival, regraft survival was found to vary with indication for first graft surgery and for FED with type of regraft procedure performed. For FED and PBK, the permutation of graft and subsequent first regraft procedure were not associated with any survival benefit for the first regraft. These reported outcomes may assist decision-making in management of a failed corneal transplant.

To compare graft survival and alloimmune responses in murine endothelial keratoplasty (EK) versus penetrating keratoplasty (PK) and to elucidate the immunological mechanisms that underlie the differential graft outcomes. Allogeneic EK and PK were performed in BALB/c recipient mice using fully disparate C57BL/6 donors; syngeneic EK recipients served as controls. Graft clarity was monitored over 16 weeks by slitlamp biomicroscopy and scored using standardized opacity grading. Anterior segment optical coherence tomography (AS-OCT) was used to measure central corneal thickness. Graft survival was assessed using Kaplan-Meier analysis. Immunohistochemistry and confocal microscopy were performed to evaluate corneal endothelial cell (CEnC) integrity through ZO-1 staining. T-cell-mediated alloimmunity was assessed using intracellular IFN-γ staining (flow cytometry) and ELISPOT assays targeting both direct and indirect antigen presentation pathways. PK allografts exhibited significantly higher corneal opacity and lower survival (50%) than allogeneic EK grafts (71.4%, P < 0.0001). AS-OCT showed that corneal edema was highest in rejected PK grafts at 4 weeks and in rejected EK grafts at 16 weeks, with EK displaying a more gradual increase in thickness. Flow cytometry revealed significantly greater frequencies of IFN-γ + CD4 + T cells in PK recipients compared with EK recipients ( P < 0.001). ELISPOT assays demonstrated a more robust Th1 response in PK through both the direct and indirect sensitization pathways. Corneal endothelial cell (CEnC) density was significantly reduced in rejected EK and PK grafts compared with their respective accepted counterparts ( P < 0.01), whereas CEnC density was comparable between accepted EK and PK grafts. EK grafts exhibit higher graft survival rates and significantly reduced activation of host T-cell responses compared with PK grafts, which may be attributed to lower frequencies of graft-borne antigen presenting cells, thus resulting in a milder Th1-mediated immune response.

Purpose:To evaluate Descemet membrane endothelial keratoplasty (DMEK) for failed endothelial keratoplasty (EK).Methods:We reviewed 362 consecutive DMEK cases for failed EK (Descemet stripping endothelial keratoplasty (DSEK) or DMEK), 118 for early EK failure, and 244 for late failure in 333 eyes of 323 patients without penetrating keratoplasty. Rejection and graft survival rates were assessed with Kaplan–Meier analysis.Results:Overall, 85% of cases had 1 prior EK and 15% had 2 to 5. The rate of medically or surgically managed glaucoma was 21% in eyes with 1 failed EK, 51% in eyes with 2, and 80% in eyes with ≥3, P <0.0001. The mean postoperative corrected visual acuity was 20/25 ± 1 line at 1 and 5 years in eyes without vision-limiting comorbidity. The 5-year rejection episode rate was 4%. One- and 5-year survival rates of DMEK regrafts for early failure of an initial EK were 98% and 94%, respectively. One- and 5-year survival rates among all cases of DMEK for EK failure were 96% and 91% in eyes not treated for glaucoma preoperatively, 88% and 81% in eyes with medically managed glaucoma, and 88% and 30% in eyes with a trabeculectomy or tube shunt.Conclusions:DMEK for failed EK provided rapid visual rehabilitation with low risk of rejection. Graft survival was associated with glaucoma status and original indication for keratoplasty, with Fuchs dystrophy having the most favorable prognosis. Survival rates were highest in eyes treated for early failure of an initial EK.

Endophthalmitis Rates and Clinical Outcomes Following Penetrating and Endothelial Keratoplasty

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