Keratoplasty for Corneal Endothelial Disease

Abstract

We read the article by Shtein et al1Shtein R.M. Raoof-Daneshvar D. Lin H.C. et al.Keratoplasty for corneal endothelial disease, 2001–2009.Ophthalmology. 2012; 119: 1303-1310Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar on the rates of keratoplasty for corneal endothelial disease (CED) in a large cohort in the United States with interest. The researchers found that patients with CED had increased odds of undergoing keratoplasty in 2007 through 2009 relative to 2001 through 2006. In addition, individuals with CED who were older, less educated, and more economically disadvantaged were found to have significantly increased odds of undergoing keratoplasty. However, there were a few points not mentioned that we felt are also pertinent when exploring the characteristics of individuals with CED and the factors that influence their propensity to undergo keratoplastic surgery. In this study, the authors identified several diseases that lead to CED, including endothelial corneal dystrophy, corneal edema, and bullous keratopathy. However, it is unclear why they did not take these diagnoses into account in the final analysis in terms of factors affecting the odds of undergoing keratoplasty for CED. In fact, Darlington et al2Darlington J.K. Adrean S.D. Schwab I.R. Trends of penetrating keratoplasty in the United States from 1980 to 2004.Ophthalmology. 2006; 113: 2171-2175Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar reported that, based on recipient diagnosis, the trend for keratoconus, endotheliopathies, and regrafts has steadily increased in a significant manner as an indication for keratoplasty. Conversely, aphakic and pseudophakic bullous keratopathy has dramatically decreased. It may be important to note that direct comparison of the outcomes of different periods (2007–2009 vs 2001–2006) would not be appropriate, especially because the authors did not specify whether the proportion of these 3 diagnoses changed over time. The authors also leave readers with the impression that they did not include failed previous corneal grafts and herpes simplex virus endotheliitis in their study, which were also common indications for Descemet's stripping endothelial keratoplasty in previous studies.3Price M.O. Giebel A.W. Fairchild K.M. Price Jr, F.W. Descemet's membrane endothelial keratoplasty: prospective multicenter study of visual and refractive outcomes and endothelial survival.Ophthalmology. 2009; 116: 2361-2368Abstract Full Text Full Text PDF PubMed Scopus (466) Google Scholar, 4Guerra F.P. Anshu A. Price M.O. et al.Descemet's membrane endothelial keratoplasty: prospective study of 1-year visual outcomes, graft survival, and endothelial cell loss.Ophthalmology. 2011; 118: 2368-2373Abstract Full Text Full Text PDF PubMed Scopus (299) Google Scholar The failed grafts usually involved significant corneal scarring and neovascularization, and these patients tended to undergo keratoplasty for pain relief rather than to improve vision. Furthermore, in a recent study we found that the best-corrected visual acuity of both the better-seeing eye and the worse-seeing eye strongly correlated with the 25-item National Eye Institute Visual Function Questionnaire composite score in patients with ocular chemical burns.5Le Q. Chen Y. Wang X. et al.Vision-related quality of life in patients with ocular chemical burns.Invest Ophthalmol Vis Sci. 2011; 52: 8951-8956Crossref PubMed Scopus (24) Google Scholar It is not surprising that bilaterally blind individuals tend to seek medical care at an early point in their disease process because of poor vision-related quality of life. It would be interesting to examine at these factors in the multivariate analysis of outcomes of the use of keratoplasty surgery. The odds of undergoing keratoplasty for CED may increase in patients with failed graft or those who are bilaterally blind. Further study regarding the correlation between these demographic factors and the likelihood of undergoing keratoplasty is warranted. Keratoplasty for Corneal Endothelial Disease, 2001–2009OphthalmologyVol. 119Issue 7PreviewTo determine the rates of keratoplasty for corneal endothelial disease (CED) from 2001 to 2009 in a large managed care network in the United States, factors that affect which patients undergo this procedure and surgical outcomes. Full-Text PDF Author replyOphthalmologyVol. 120Issue 3PreviewWe thank Hong et al for their comments regarding our manuscript and would like to address several important issues that they raise. The focus of our paper was specifically to study keratoplasty among patients with corneal endothelial disease (CED). Exploring keratoplasty for other corneal conditions such as keratoconus, ocular burns, and infectious keratitis was beyond the scope of our study. Although we acknowledge that expanding our study to capture patients with these other corneal conditions would offer readers a more global sense of outcomes of keratoplasty surgery, a downside to such an approach is that it may not fully reflect utilization patterns and outcomes of keratoplasty specifically for CED. Full-Text PDF