Repeated Corneal Transplantation Research Articles

Repeat corneal transplantation in Southern China: Indications, surgical technique, outcomes, and risk factors for repeat keratoplasty failure.

To report the indications, surgical techniques, and outcomes of repeat keratoplasty and evaluate the risk factors for graft failure in the Chinese population. The medical records of 216 patients (243 cases) who underwent at least two keratoplasties at a leading eye hospital in southern China between 2011 and 2020 were retrospectively reviewed. Indications and surgical procedures for repeat corneal transplantation were analyzed. Kaplan-Meier survival analysis was used to determine the graft survival rate after repeat keratoplasty. A multivariable survival model was used to assess the risk factors. Repeated keratoplasties increased continuously from 2011 to 2020 (P = 0.002). The most common primary indication was infectious keratitis (38.7%), and the most common reason for repeat keratoplasty was graft rejection (30.04%). Regraft techniques included penetrating keratoplasty (PK) in 165 cases (67.9%), deep lamellar keratoplasty (DALK) in 52 cases (21.40%), and endothelial keratoplasty (EK) in 26 cases (10.7%). Median survival was 5.3, 6.8, and 6.4 years for PK, DALK, and EK, respectively. The 5-year survival rate was 53.5%, 66.6%, and 69.8% for PK, DALK, and EK, respectively. The median LogMAR visual acuity was 1.4 for PK, 0.75 for DALK, and 1.2 for EK at the end of the follow-up. Multivariate analysis revealed that graft rejection is a risk factor for repeat keratoplasty failure (P = 0.002). DALK and EK may provide better outcomes than PK in treating graft failure. Preventing and treating postoperative graft rejection may be key to improving regraft survival. These findings will aid in the management of failed corneal grafts.

Suppression of Neovascularization by Topical and Subconjunctival Bevacizumab After High-Risk Corneal Transplantation

To assess the effectiveness of topical and subconjunctival bevacizumab in suppressing vascularization in graft and host bed after high-risk corneal transplantation. Secondary analysis of prospective, randomized, double-blind, placebo-controlled multicentric clinical trial. The study includes patients aged > 18 years who underwent high-risk penetrating keratoplasty, which was defined as corneal vascularization in ≥ 1 quadrants of the corneal graft and host bed, excluding the limbus. Patients were randomized to treatment and control groups. The patients in the treatment group received subconjunctival injection of bevacizumab (2.5 mg/0.1 ml) on the day of the procedure, followed by topical bevacizumab (10 mg/ml) 4 times per day for 4 weeks. The patients in control group received injection of vehicle (0.9% sodium chloride) on the day of procedure, followed by topical vehicle (carboxymethylcellulose sodium 1%) 4 times a day for 4 weeks. Vessel and invasion area of vessels in the corneal graft and host beds. This study included 56 eyes of 56 patients who underwent high-risk corneal transplantation, with equal numbers in the bevacizumab and vehicle (control) treatment groups. The mean age of patients who received bevacizumab was 61.2 ± 15.9 years, and the mean age of those treated with vehicle was 60.0 ± 16.1 years. The vessel area at baseline was comparable in the bevacizumab (16.72% ± 3.19%) and control groups (15.48% ± 3.12%; P= 0.72). Similarly, the invasion areas were also similar in the treatment (35.60% ± 2.47%) and control (34.23% ± 2.64%; P= 0.9) groups at baseline. The reduction in vessel area was significantly higher in the bevacizumab-treated group (83.7%) over a period of 52 weeks compared with the control group (61.5%; P < 0.0001). In the bevacizumab-treated group, invasion area was reduced by 75.8% as compared with 46.5% in the control group. The vessel area was similar at 52 weeks postprocedure in cases of first (3.54% ± 1.21%) and repeat (3.80% ± 0.40%) corneal transplantation in patients who received bevacizumab treatment. In the vehicle-treated patients, the vessel area was significantly higher in repeat (9.76% ± 0.32%) compared with first (8.06% ± 1.02%; P < 0.0001) penetrating keratoplasty. In the bevacizumab treatment group, invasion areas at week 52 were comparable in first (11.70% ± 3.38%) and repeat (11.64% ± 1.74%) procedures, whereas invasion area was significantly higher in repeat (27.87% ± 2.57%) as compared with first (24.11% ± 2.17%) penetrating keratoplasty in vehicle-treated patients. In patients undergoing vascularized high-risk corneal transplantation, bevacizumab is efficacious in reducing vascularization of corneal graft and host bed, thereby reducing the risk of corneal graft rejection in vascularized host beds. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Risk factors of cytomegalovirus infection in patients with failed corneal grafts

Objective: To investigate the levels of cytomegalovirus (CMV) infection and associated risk factors in corneal transplant recipients who experienced transplant failure. Methods: This was a case-control study. Clinical data from 576 cases (576 eyes) of patients who underwent repeat corneal transplant surgery at the Department of Ophthalmology, Peking University Third Hospital, due to corneal transplant failure from January 2016 to May 2022 were collected. Of these, 305 were male and 271 were female, with a median age of 44.0 (0.7, 91.0) years. The CMV infection rate was analyzed based on the detection of CMV DNA in aqueous humor or corneal tissue during corneal transplant surgery. Patients were divided into the CMV group (CMV DNA positive) and the control group (herpes virus DNA negative). The main research indicators included the CMV infection rate, clinical characteristics, and risk factors in corneal transplant recipients. Chi-square tests and binary logistic analysis were used to compare differences between the two groups in general information, systemic diseases, ocular lesions, ocular surgical history, and local and systemic medications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for each CMV infection risk factor. Results: The overall CMV infection rate was 21.9%(126/576), with annual rates ranging from 10.9% to 37.7% from 2016 to 2021. After applying inclusion and exclusion criteria, 378 patients were included in the control trial, with 126 in the CMV group and 252 in the control group. Statistically significant differences between the two groups were observed in systemic immune-related corneal lesions [CMV group: 38 (30.2%), control group: 26 (10.3%)], local immune and inflammatory corneal lesions [CMV group: 46 (36.5%), control group: 40 (15.9%)], congenital corneal opacity [CMV group: 46 (36.5%), control group: 48 (19.0%)] total number of corneal transplants (CMV group: 178 times, control group: 276 times), corneal deep neovascularization crossing the graft [CMV group: 104 (82.5%), control group: 68 (27.0%)] and severe opacity [CMV group: 44 (34.9%), control group: 30 (11.0%)]. Binary logistic regression analysis showed that systemic immune-related corneal lesions (OR=4.044, 95%CI 1.810-9.033, P<0.001), local immune and inflammatory corneal lesions (OR=3.554, 95%CI 1.569-8.052, P=0.002), congenital corneal opacity (OR=2.606, 95%CI 1.216-5.589, P=0.014), total number of corneal transplants (OR=3.206, 95%CI 1.753-5.864, P<0.001), corneal deep neovascularization crossing the graft (OR=8.347, 95%CI 3.967-17.559, P<0.001), and severe opacity (OR=3.063, 95%CI 1.221-7.682, P=0.017) were independent risk factors for CMV infection after corneal transplant. Conclusions: CMV infection was present in more than 1/5 of corneal transplant recipients who experienced transplant failure. CMV infection after corneal transplant may be related to immune rejection reactions and ocular inflammatory responses. Inflammatory corneal lesions associated with systemic or local immune abnormalities, congenital corneal opacity, and multiple corneal transplants may exacerbate the levels of inflammatory factors during the perioperative period of corneal transplant, increasing the risk of post-transplant CMV infection, leading to the infiltration of deep neovascularization and severe opacity in the cornea.

Outcomes of XEN Stent in Patients With Glaucoma and Previous Corneal Transplantation.

The XEN stent safely and effectively controls intraocular pressure in select patients with history of corneal transplantation. Glaucoma is a common complication after corneal transplantation and can be difficult to manage in these patients. This study reports outcomes of XEN stent implantation in eyes with glaucoma in the setting of previous corneal transplantation. Noncomparative retrospective case series including eyes with a history of corneal transplantation and subsequent XEN stent implantation by a single glaucoma surgeon in Surrey, British Columbia, between 2017 and 2022. The analysis included patient demographics, pre and postoperative intraocular pressure (IOP), pre and postoperative glaucoma medications, peri and postoperative complications and interventions, and incidence of repeat corneal transplantation and additional glaucoma procedures to control IOP. Fourteen eyes with previous cornea transplantation underwent XEN stent implantation. Mean age was 70.1 years (range: 47-85y). Mean follow-up was 18.2 months (range: 1.5-52mo). The most common glaucoma diagnosis was secondary open angle glaucoma (50.0%). There was a significant reduction in IOP and the number of glaucoma agents at all postoperative time points ( P < 0.05). IOP decreased from 32.7 ± 10.0mm Hg at baseline to 12.5 ± 4.7mm Hg at the most recent follow-up. Glaucoma agents decreased from 4.0 ± 0.7 to 0.4 ± 1.0. Two eyes required additional glaucoma surgery to control IOP, with an average time to reoperation of 7 weeks. Two eyes underwent repeat corneal transplantation, with an average time to reoperation of 23.5 months. In selected patients with previous corneal transplants and refractory glaucoma, the XEN stent was safely implanted and effectively reduced IOP in the short term.

Review of clinical trials addressing the Boston Keratoprosthesis

ObjectifLa kératoprothèse (KPro) de Boston est de plus en plus reconnue en tant que solution de rechange chez les patients qui présentent une atteinte grave de la cornée dans un contexte où la kératoplastie perforante classique a peu de chances de réussir. Notre article résume les données issues d’études cliniques réalisées à ce jour sur la KPro et aborde les études actuelles. NatureRevue de synthèse systématique. MéthodesNous avons lancé une recherche dans les bases de données PubMed, Ovid MEDLINE, Cochrane CENTRAL et ClinicalTrials.gov en vue d'identifier les études cliniques pertinentes sur la KPro publiées jusqu'en septembre 2021. Toutes les études publiées ont été incluses dans notre revue de synthèse. RésultatsOn a recensé 6 études cliniques publiées de même que 6 études cliniques en cours sur la KPro de Boston. Le nombre de patients dans chaque étude s’échelonnait de 8 à 37. L’âge moyen des patients de chaque étude variait de 39 à 62 ans. Les patients ont été suivis en moyenne pendant 36,3 ± 41,8 mois. La moitié des études cliniques (3 sur 6) sur la KPro étaient randomisées. L'indication de la KPro était précisée dans 67 % des études (4 sur 6) : la KPro a été utilisée en première intention dans 22 % des yeux uniques (13 sur 58), tandis qu'elle a été implantée après un échec de la greffe de cornée dans 41 % des yeux uniques (24 sur 58), lorsque ce détail était précisé. L'outil RoB 2 (version 2 du Revised Cochrane risk-of-bias tool for randomized trials) a servi à évaluer la qualité des études et le risque de biais. Ce dernier s'est révélé faible dans 50 % des études (3 sur 6), moyen dans 33 % des études (2 sur 6) et élevé dans 17 % des études (1 sur 6). ConclusionsIl existe peu d’études cliniques (publiées en en cours) portant sur la KPro de Boston, sans compter qu'aucune ne compare directement les résultats obtenus avec la KPro à ceux d'une nouvelle greffe de cornée. Il est nécessaire de réaliser des études cliniques de longue durée sur la KPro afin d'amasser des données probantes de qualité, afin de faciliter la prise de décision clinique.

Keratoplasty in the United States: Trends and Indications From 2015 to 2020.

The aim of this study was to report trends in keratoplasty techniques and indications in the United States from 2015 to 2020. This retrospective review of annual reports from the Eye Bank Association of America assessed domestic corneal graft distribution and surgical indication data for various types of keratoplasty. Trends in procedure volume and indications from 2015 to 2020 were analyzed using the Cochran-Armitage test. The total number of corneal transplants increased from 47,903 in 2015 to 49,143 in 2019, with a decline to 42,257 in 2020, most likely due to COVID-19. Penetrating keratoplasty (PK) volume decreased from 2015 to 2020 (19,160-15,402, 40% to 36.4%, P < 0.001), continuing a trend from the previous decade. Descemet membrane endothelial keratoplasty as a percentage of all keratoplasty procedures increased (9.8%-27.8%, P < 0.001), whereas Descemet stripping automated endothelial keratoplasty (47%-33.9%, P < 0.001) and anterior lamellar keratoplasty (ALK) decreased (2.3%-1.2%, P < 0.001).From 2017 to 2020, repeat corneal transplant was the most common specific indication for PK while ectasias/thinnings decreased in prevalence (15.6%-11.5%, P < 0.001). Ectasias/thinnings and endothelial dystrophy remained the leading indications for ALK and endothelial keratoplasty, respectively. From 2015 to 2020, keratoplasty trends in the United States showed a continuation of the decrease in PK and increase in Descemet membrane endothelial keratoplasty observed in the previous decade. The most common domestic indications from 2017 to 2020 have been repeat corneal graft, endothelial dystrophy, and ectasias/thinnings for PK, EK, and ALK, respectively.

Repeat corneal transplantation: indication, surgical technique, and early graft failures trends in France from 2004 to 2019.

To investigate the repeat corneal transplantation trend in France from 2004 to 2019. Review of the prospectively compiled French Biomedicine Agency electronic database containing all corneal transplantation records from 2004 to 2019. The surgical technique, demographic characteristics, diagnosis, and previous graft data were retrieved and analyzed using the Cochran-Armitage trend test. A total of 66,584 corneal transplantations were performed, 51,260 of which were first grafts and 15,324 (23%) were regrafts. For regrafts, 77% were penetrating keratoplasties (PK) and 19.6% were lamellar keratoplasties (LK). Age, hypertonia, glaucoma, trauma, lens surgery, immune disorders, diameter > 8.5mm, and neovessels in > 2 quadrants were associated with a higher rate of repeat keratoplasty. Keratoconus, secondary endothelial dystrophy, and Fuchs' dystrophy were the principal indications for regrafting. When a previous graft failed, it occurred earlier for patients with LK (4.6years, median = 2, SD = 7.54) than PK (8.48years, median = 5, SD = 9.51). Failure within a year was the reason why 28.3% of the LK regrafts and 12.5% of PK regrafts were performed, while for failure within two years these values were 49.9% and 27.8%, respectively. Graft survival decreased with the number of repeat keratoplasty, being more pronounced after a second LK regraft and after a first PK regraft. The number of LK regrafts increased continuously, and 1/3 were performed for failure within the year. This rate increased until 2015, after which it stabilized until 2019, probably due to the better mastery of the technique.

Post-corneal transplant Candida keratitis - Incidence and outcome.

Purpose:To report the risk factors, clinical characteristics, and outcomes of Candida keratitis following corneal transplantation in India.Methods:On retrospective review of medical records of 789 patients, 31 eyes developed a graft infection following corneal transplantation or keratoprosthesis and we could identify the Candida infection in only five. These cases were operated at two tertiary care centers in India. These five records were reviewed for demographics, risk factors (local and systemic) for graft infection, characteristics of infective lesion, corneal scraping results, treatment plan, and the final outcome following management.Results:The median age of the subjects with the Candida graft infection was 62.4 ± 10.33 years (range, 62–71 years). All patients were males. The predominant risk factors included repeat corneal transplantation (5/5), prolonged usage of topical steroids (5/5), and epithelial defects (4/5). The clinical characteristics included infiltrates of variable configuration like powdery deposits, white plaque, fluffy white infiltrate, and crystalline keratopathy. The smear showed budding yeasts in all five cases whereas culture was positive in four out of five cases. The final outcome with antifungals (systemic [4/5] and topical [5/5]) is variable. Two eyes underwent evisceration, two eyes had scar formation in the failed grafts, and one patient succumbed to the systemic disease 1-month post-corneal infection.Conclusion:Candida keratitis, in India, seems to be an emerging pathology following corneal transplantation and has a varied presentation. Though the outcomes following management seem to be grim, however, such infection can easily be avoided by a timely reduction of the risk factors.

Metabolic therapy of predicted complications in immunocompromised recipients before repeated corneal transplantation

One of the topical problems of modern ophthalmotransplantology is the graft engraftment after repeated keratoplasty. During repeated corneal transplantation, the frequency of graft rejection increases significantly. The study included 121 patients aged 19 to 89 years with corneal graft failure, who were scheduled for repeated corneal transplantation. Immunophenotyping of major and small populations of peripheral blood lymphocytes was performed by flow cytometry (CytoFlex BC, USA). The intensity of energy metabolism in lymphocyte populations was determined by the activity of succinate dehydrogenase and NADH dehydrogenase by immunocytochemical method using flow cytometry. An increase in the content of B lymphocytes (p = 0.004) and a decrease in Th17 lymphocytes (p = 0.013) were revealed after the use of a course of metabolic therapy. Against the background of therapy, the activity of SDH in the T lymphocyte population significantly increases (p = 0.034). In addition, in the studied populations of lymphocytes in the recipient group, against the background of metabolic therapy, the normalization of SDH activity is observed: the number of recipients with low and high enzyme activity decreases. After a course of metabolic therapy, a significant decrease in NADHDH activity was revealed (p = 0.034). Indicators of lymphocyte populations and mitochondrial enzyme activity in recipients after a course of metabolic therapy indicated a more favorable prognosis for repeated corneal transplantation. Evaluation of the results of repeated keratoplasty a year after surgery showed that 59 recipients received transparent graft engraftment, and in 62 patients the graft became cloudy in the period from 1 to 8 months after surgery. In the group of patients with transparent graft engraftment, the percentage of recipients receiving metabolic therapy was significantly higher than in the group of recipients with graft opacity (41%±2.05% vs 21%±2.91%, p 0.001). Conducting metabolic therapy before surgery reduces the number of realized unfavorable prognoses of the result of rekeratoplasty, and monitoring the activity of dehydrogenases and the content of lymphocyte populations allows us to evaluate the effectiveness of therapeutic and preventive measures in immunocompromised recipients.

Indications and Surgical Techniques for Repeat Corneal Transplantation in Eastern China: A Twelve-Year Study.

Purpose To analyze the indications and surgical procedures for repeat keratoplasty in eastern China from 2008 to 2019. Methods This retrospective descriptive study included 418 eyes of 411 patients who underwent no less than 2 keratoplasties at the Eye, Ear, Nose and Throat Hospital of Fudan University from 2008 to 2019. Medical charts were reviewed. The primary indications for repeat keratoplasty, the reasons for regrafting, and the surgical techniques used in the treatment were collected and analyzed. Results Among 418 eyes, 337 eyes (80.6%) had one repeat keratoplasty, and 81 eyes (19.4%) had multiple repeat keratoplasties (≥2 repeat keratoplasties). The median interval between the initial keratoplasty and the first repeat keratoplasty was 25 months, and that between two keratoplasties after the first repeat keratoplasty was 27.5 months. Infectious keratitis was the leading primary indication for single repeat keratoplasty (80 cases, 23.7%) and multiple repeat keratoplasties (19 cases, 23.5%). The second most common primary indication was bullous keratopathy for single repeat keratoplasty (49 eyes, 14.5%) and chemical injury for multiple repeat keratoplasties (14 eyes, 17.3%). The main reason for regrafting was allograft rejection (262 cases, 49.3%), followed by endothelial dysfunction (92 cases, 17.3%), and for vision improvement after tectonic keratoplasty (60 cases, 11.3%). Penetrating keratoplasty (PKP) was the major technique used in repeat keratoplasty (447 cases, 84.2%). However, Descemet stripping endothelial keratoplasty was more frequently used than PKP (72.4% vs. 27.6%, P < 0.001) in the treatment of failed endothelial keratoplasty. Conclusion Infectious keratitis was still the leading cause of repeat keratoplasty in eastern China. Although PKP remains the major technique of repeat keratoplasty, the application of customized lamellar keratoplasty has greatly expanded in the last decade. Cautious selection of indications, surgical techniques, and timing for surgery is crucial for a good prognosis after repeat keratoplasty.

Clinical Characteristics and Outcomes of Short-term Repeat Corneal Transplantation

ABSTRACT Purpose To explore the primary indications, direct causes and graft survival of short-term repeat keratoplasty. Methods An analytical cross-sectional study. Results The primary indications for keratoplasty were infectious keratitis (67.9%) and immune keratopathy (12.8%). The direct causes of graft failure were infectious ulcer (43.6%) and recurrence (30.8%). Pre-operative hypopyon (P = 0.017, HR = 1.757) and use of decellularized porcine corneas as grafts (P = 0.005, HR = 2.690) were independent risk factors for graft failure. The Kaplan–Meier analysis revealed that the 1-year survival rate of 88 repeat grafts was 85.2%, and the 5-year survival rate was 79.2%. The survival rates of the repeat grafts were significantly higher than those of the first grafts (P < 0.001). Conclusion Infectious keratitis is the most common indication of short-term graft failure and is often failed by infectious ulcer and keratitis recurrence. While the decellularized porcine cornea is a promising application in developing countries, certain difficulties, such as graft melting, remain unresolved.

Higher incidence of penetrating keratoplasty having effects on repeated keratoplasty in South Korea: A nationwide population-based study.

PurposeTo investigate the incidence of corneal transplantation and identify rates and risk factors of repeated corneal transplantation in South Korea.MethodsThis is a retrospective population-based cohort study using the Korean National Health Insurance System database. Among the entire South Korean population (N = 51,827,813), we included those who underwent corneal transplantation more than once between January 2006 and December 2016, and analyzed the annual incidence of keratoplasty. The person-year incidence of repeated keratoplasty after the first operation was calculated according to risk factors including age group, sex, income level, surgical method, surgical etiology, and presence of major systemic diseases. Cox regression analysis was employed to evaluate the hazard ratios of those risk factors on repeated keratoplasty.ResultsA total of 9,452 cases of corneal transplantation occurred from January 2006 to December 2016. The average annual incidence of corneal transplantations was 1.694 per 100,000. The proportion of penetrating keratoplasty steadily decreased from 92.22% in 2006 to 77.81% in 2016. The average incidence of repeated keratoplasty among those who underwent corneal transplantation at least once was 43.24 per 1,000 person-years. Males had a greater incidence of repeated keratoplasty compared to females (males: 47.66 per 1,000, females: 36.04 per 1,000). The age group from 20 to 39 years demonstrated the lowest incidence of repeated keratoplasty at 24.94 per 1,000. Keratoconus had the lowest incidence of repeated keratoplasty (22.82 per 1,000).ConclusionThis study may provide a better understanding of corneal diseases, help predict disease burden, and plan health care systems accordingly in South Korea.

Repeat corneal transplantation in Auckland, New Zealand: Indications, visual outcomes and risk factors for repeat keratoplasty failure.

In New Zealand, repeat keratoplasty has become the second leading indication for corneal transplantation. To report the indications, outcomes and survival of repeat keratoplasty and evaluate the risk factors for graft failure. Retrospective study in a public corneal service. Two hundred nineteen patients undergoing 279 repeat keratoplasty procedures during 1991-2017. The New Zealand National Eye Bank prospectively collects data on all corneal transplants. This was utilized to identify patients undergoing repeat keratoplasty in Auckland. Clinical records were retrospectively reviewed. Graft survival and visual outcome. The repeat keratoplasty technique was penetrating keratoplasty (PK) in 242 cases (86.7%) and endothelial keratoplasty in 37 (13.3%). The most common primary indication was keratoconus (46.6%). The most common indication for repeat keratoplasty was endothelial decompensation (37.6%). For PK performed as a repeat keratoplasty, the median survival in years was 12.0 for first, 3.5 for second and 2.3 for third repeat keratoplasty. Keratoconus had the longest graft survival (median 13.0 years). In surviving grafts, median visual acuity was 6/15 at 1 year and 6/12 at 2 years. On multivariate analysis, regraft number (P = .022), non-European ethnicity (P = .007), concurrent surgical procedure (P < .0005), lower donor endothelial density (P = .028), previous glaucoma surgery (P < .0005), postoperative raised intraocular pressure (P = .001) and graft rejection (P = .032) were associated with keratoplasty failure. Repeat keratoplasty survival is affected by multiple interacting factors and prognosis worsens with each subsequent regraft. These results will help guide clinicians in addressing patients' individual risk factors when embarking on repeat corneal transplant surgery.

Trends in corneal transplant surgery in Ireland: indications and outcomes of corneal transplant surgery and intraocular lens opacification following Descemet’s stripping automated endothelial keratoplasty

To evaluate the indications for corneal transplantation, the procedures carried out, and the postoperative outcomes and to compare these with previous Irish corneal transplant studies. A retrospective review of the case notes of all patients who underwent corneal transplantation under the care of a single surgeon, from 2008 to 2015, was performed. The risk factors for postoperative complications including transplant failure were examined. During the period studied, 42 corneal transplant surgeries were carried out on 40 eyes of 38 patients, 24 of whom were male (63%), median age at surgery was 62years (range 23-96years). The most common indication for transplantation was pseudophakic corneal decompensation associated with Fuch's endothelial dystrophy (FED) (n=13). Seventeen penetrating keratoplasties, 23 lamellar keratoplasties, and two amniotic membrane transplant procedures were carried out. Transplant failure resulting in corneal oedema or repeat corneal transplant surgery (n=4, 10%), was associated with previous transplant failure in the eye; odds ratio (OR)=1.58 (p=0.05), and with comorbid FED, OR=1.50 (p=0.02). Intraocular lens opacification occurred in one lens following DSAEK, giving an incidence rate of 7%. Pseudophakic corneal decompensation is the commonest indication for corneal transplant surgery, with lamellar keratoplasty the most frequent approach in our cohort, reflecting developments observed in corneal transplant surgery elsewhere. Prior corneal transplant failure and Fuch's dystrophy remain important risk factors for failure. The risk of intraocular lens opacification and its potential effects on vision should be elaborated prior to endothelial keratoplasty.

Incidence of Presumed Iatrogenic Graft Failure in Descemet Stripping Automated Endothelial Keratoplasty

To evaluate presumed iatrogenic graft failure (PIGF) in Descemet stripping automated endothelial keratoplasty (DSAEK). Deidentified data were collected retrospectively from the Illinois Eye Bank between April 2007 and May 2010. PIGF was defined as cases in which a repeat corneal transplant was performed <8 weeks after an initial DSAEK. Data collected for each case included days between initial DSAEK and regraft, regraft type (DSAEK vs. penetrating keratoplasty), precut versus surgeon-cut tissue, and number of DSAEKs distributed to individual surgeons. Ninety-three cases of PIGF were identified for a group of 46 surgeons who received 2504 corneas. Nine PIGF cases from 4 surgeons in cornea fellowships were analyzed separately. Individual surgeon failure rate and overall failure rate were calculated. Analysis of the overall failure rate was conducted without cases performed by surgeons who train fellows. Effect of surgical experience on PIGF was analyzed. Overall presumed iatrogenic DSAEK failure rate was 3.66% (84 PIGF cases divided by 2294 corneas). Within the group of 4 surgeons that trained fellows, the failure rate was 4.29% (9 cases PIGF divided by 210 corneas). Average time to regraft was 27.5 ± 17.4 days. Initial diagnoses included Fuchs dystrophy, pseudophakic bullous keratopathy, edema, and other disease states. Average donor and recipient ages were 54.3 ± 13.0 and 71.7 ± 11.3 years, respectively. Use of precut versus surgeon-cut tissue did not affect overall failure rates. Failure rates of less experienced surgeons (21.8% ± 10.8%) were higher than more experienced surgeons (1.5% ± 1.4%). Overall, DSAEK failure rates improve as surgeons gain experience. Failure rates in cornea fellowship programs are not excessive.

Comparison of outcomes of penetrating keratoplasty versus Descemet’s stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure due to corneal edema

To evaluate the outcomes of repeat corneal transplantation, either penetrating keratoplasty (PKP) or Descemet's stripping automated endothelial keratoplasty (DSAEK), for penetrating keratoplasty grafts which failed due to corneal edema. The charts of 24 eyes with failed PKP grafts, due to corneal edema, which underwent a repeat corneal transplant (PKP in 17 eyes [Group 1] and DSAEK in seven eyes [Group 2]) between 2003 and 2007 were retrospectively reviewed. There was no statistically significant difference in the median postoperative visual acuity between the two groups at 1, 2, or 3 years. In Group 1, two (18%) eyes had a final visual acuity ≥ 20/40, in contrast to four (80%) eyes in Group 2, which was statistically significant (P = 0.038). Seven (41%) of the Group 1 eyes developed postoperative complications compared to only one (14%) eye in Group 2. Eleven (65%) of the Group 1 eyes and five (71%) of Group 2 eyes had clear grafts on the last examination. There was no statistically significant difference in the graft survival rate for Group 1 versus Group 2 at 3 years (57.9% vs 68.6%, P = 0.507). There was a trend towards better postoperative visual acuity, a lower postoperative complication rate, and a higher graft survival rate in eyes that underwent DSAEK rather than repeat PKP for graft failure secondary to corneal edema. Given this small, retrospective study, future studies comparing repeat PKP with DSAEK are warranted to determine which procedure allows for improved outcomes.

Management of Corneal Graft Rejection – A Case Series Report and Review of the Literature

PURPOSE: To report long-term results in a case series of patients treated with systemic immune suppression for prevention of penetrating keratoplasty (PKP) graft rejection. DESIGN: Retrospective noncomparative chart review. PARTICIPANTS: Three patients presented with PKP graft failure. METHODS: Patients received oral prednisone, azathioprine and cyclosporine to prevent rejection of repeat corneal transplant. Patients received repeat PKP and graft outcome was reported. MAIN OUTCOME MEASURES: Visual acuity and graft survival were recorded. RESULTS: Mean age was 55 years, two male and one female. Mean follow-up period was 37 months (range 24-46). All three patients completed the treatment protocol with minimal adverse effects. All grafts remained clear over observational period. CONCLUSION: Our study suggests that systemic immune suppression with 2 or more agents may be helpful to prevent corneal graft rejection in high-risk patients.

De Barsy syndrome and ATP6V0A2-CDG

We read with interest the nice review of Morava et al1 on the autosomal recessive cutis laxa syndromes. The authors mention the De Barsy syndrome and state that the genetic background of the De Barsy syndrome has not yet been identified. However, in the paper by Kornak et al2 on impaired glycosylation and cutis laxa caused by mutations in ATP6V0A2 (ATP6V0A2-CDG according to the novel nomenclature3, 4), one of the patients (see patient CoFe in Table 1 of Kornak et al2) shows the full clinical picture of the De Barsy syndrome, including cutis laxa, facial dysmorphy, dwarfism, psychomotor retardation, dystonia, congenital hip dysplasia, and corneal dystrophy necessitating repeated corneal transplantation. These data suggest that a subgroup of patients with De Barsy syndrome5 belongs to the spectrum of ATP6V0A2-CDG. Another cause of De Barsy syndrome has very recently been identified as mutations in PYCR1, coding for a mitochondrial enzyme involved in proline metabolism.6 Therefore, we recommend a systematic screen for ATP6V0A2-CDG and for mutations in PYCR1 in patients with De Barsy syndrome.

Outcomes of LASIK and PRK in Previous Penetrating Corneal Transplant Recipients

To evaluate the safety and efficacy of excimer laser refractive surgery in correcting refractive error in eyes that have undergone previous penetrating keratoplasty (PK). Twenty-three keratorefractive procedures on 16 eyes from 16 consecutive subjects were evaluated between 2002 and 2008. Each patient presented a previous history of a PK with subsequent postoperative myopia and astigmatism. Keratometric value, manifest refraction, best-corrected visual acuity, uncorrected visual acuity, and complications were determined. There were a total of 14 photorefractive keratectomy (PRK) procedures performed on 11 eyes and 9 laser in situ keratomileusis (LASIK) procedures performed on 5 eyes. In the PRK group, the preoperative post-PK manifest refractive spherical equivalent and cylindrical error were -6.22 +/- 6.23 diopter and 5.23 +/- 2.26 D, respectively. The PRK postoperative manifest refractive spherical equivalent and cylindrical error were -3.61 +/- 4.23 D (P=0.25) and 3.21 +/- 1.78 D (P=0.02), respectively. In the LASIK group, the preoperative post-PK manifest refractive spherical equivalent and cylindrical error were -3.05 +/- 3.29 D and 4.11 +/- 2.38 D, respectively. The LASIK postoperative manifest refractive spherical equivalent and cylindrical error were -1.51 +/- 2.02 D (P=0.24) and 2.08 +/- 1.26 D (P=0.03), respectively. There was a 2-line or greater improvement of uncorrected visual acuity in 8 of the 14 PRK treatments and 5 of the 9 LASIK treatments. There were two episodes of acute graft rejection. One of the episodes resolved with topical and oral corticosteroids, and the other episode required a repeat corneal transplantation. PRK and LASIK are effective tools in reducing surgically induced astigmatism after penetrating corneal transplantation in most patients in this case series. The reduction of astigmatism may allow improved contact lens or spectacle fitting to achieve best-corrected binocular visual acuity.

The Boston Type I Keratoprosthesis: Improving Outcomes and Expanding Indications

To report the usefulness of the Boston type I keratoprosthesis (Massachusetts Eye and Ear Infirmary, Boston, MA) in the management of corneal opacification, corneal limbal stem cell failure, or both in a large single-surgeon series. Retrospective review of consecutive clinical case series. All patients undergoing keratoprosthesis implantation by a single surgeon (AJA) between May 1, 2004, and May 31, 2008. Data were collected regarding the preoperative characteristics of each eye undergoing keratoprosthesis implantation, the surgical procedure(s) performed, and the postoperative course. Statistical analysis was performed to identify factors influencing the incidence and severity of postoperative complications. Interval visual acuities, keratoprosthesis retention, and significant postoperative complications. Fifty-seven keratoprosthesis procedures were performed in 50 eyes of 49 patients. The primary indication for surgery was repeat corneal transplantation failure (68%), although no prior corneal surgery had been performed in 16% of eyes. Preoperative visual acuity was 20/200 or worse in all eyes, with 88% of eyes having preoperative vision of counting fingers, hand movements, or light perception. The percentage of eyes with postoperative visual acuity of 20/100 or better was 67% at 6 months (n = 45), 75% at 1 year (n = 28), 69% at 2 years (n = 13), and 100% at 3 years (n = 7). In the 31% of patients in whom preoperative vision in the contralateral eye was 20/50 or better, the postoperative vision in the operative eye improved to 20/50 or better in 47% at the last follow-up (average, 18 months; range, 4-49 months). The overall keratoprosthesis retention rate was 84% at an average follow-up of 17 months (79 person-years of follow-up), with 100% retention in 8 eyes with no history of prior corneal transplantation (14.8 person-years of follow-up). The most common postoperative complications were retroprosthetic membrane formation (22 eyes) and persistent epithelial defects (19 eyes). No cases of infectious endophthalmitis were encountered, and only 1 patient with a history of glaucoma required additional glaucoma surgery during the postoperative period. The Boston type I keratoprosthesis is an effective means of managing repeat corneal graft failure and corneal limbal stem cell failure with or without corneal opacification in patients with both unilateral and bilateral visual impairment.