clinical outcomes and risk factors for graft failure after keratoplasty for macular corneal...
TRANSCRIPT
Clinical Outcomes and Risk Factors for Graft Failure After Keratoplasty for
Macular Corneal Dystrophy
Jagadesh C. Reddy Somasheila I. Murthy, Prashant Garg,
Pravin K. Vaddavalli
The authors have no financial interests in the subject matter of this presentation
ID: 17637
Purpose
The aim of this study was to compare visual
acuity, clinical outcomes, complications, and
risk factors for graft failure after deep
anterior lamellar keratoplasty (DALK) and
penetrating keratoplasty (PK) for macular
corneal dystrophy
Methods
• Study design: Retrospective review of
clinical records of 104 patients with MCD who
underwent corneal transplantation and
followed up for at least 12 months
• Study location: Cornea service, LV Prasad
Eye Institute, India
• Study duration: April 2001 to June 2009
• Study ethics: Approved by the institutional
review board and was conducted in strict
adherence to the tenets of the Declaration of
Helsinki
ResultsParameter DALK PK
Number of eyes (patients)
21 (20) 109 (84)
Mean age (SD, range) years
30 (11.87, 5-50) 34 (11.53, 18-65)
Gender, male : female (%)
14:6 (70:30) 48:36 (57:43)
Laterality, RE:LE:BE 9:10:1 34:25:25
Mean follow-up (SD, Range) in months
17 (8.80, 12-46 ) 43 (24.13, 12–104)
Mean donor size (SD) 8.02 (0.28) mm 8.11 (0.22) mm
Mean recipient size (SD)
7.59 (0.24) mm 7.64 (0.23) mm
DALK-deep anterior lamellar keratoplasty, PK-penetrating Keratoplasty, RE-right eye, LE-left eye, BE-both eyes, SD-standard deviation, mm-millimeters
Table-1, Patient characteristics and surgical data of the two groups
ResultsParameter DALK PK P
value*Mean pre-operative LogMAR BCVA (SD)
1.09 (0.57) 1.27 (0.61) 0.22
Mean Log MAR BCVA at 3 months (SD) 0.58 (0.39) 0.45 (0.51) 0.52
Mean Log MAR BCVA at 12 months (SD)
0.43 (0.39) 0.45 (0.51) 0.89
Mean Log MAR BCVA at final follow-up (SD)
0.45 (0.59) 0.56 (0.67) 0.50
Mean Refractive spherical equivalent at 12 months (SD)
1.72 (3.08) D
0.34 (3.98) D
0.31
Mean Refractive spherical equivalent at final follow-up (SD)
0.72 (2.31) D
-0.63 (3.68) D
0.29
Mean cylinder (median) at 12 months -3.25 (-3.5) D
-3.30 (-3) D 0.75
Mean cylinder (median) at final follow-up
-3.31 (-3) D -2.48 (2.62) D
0.33
DALK-deep anterior lamellar keratoplasty, PK-penetrating keratoplasty, Log MAR-logarithm of the minimum angle of resolution equivalents, BCVA- best corrected distance visual acuity, SD- standard deviation, D-diopters *McNemar test was used
Table-2 Comparison of visual and refractive results between the two groups
ResultsComplication DALK PK
Intraoperative : Conversion to PK 3 -
DM micro perforation 5 -
Spontaneous expulsion of lens 0 1
Post-operative Double anterior chamber 9 -
Wound leak: re-suturing 0 2Graft dehiscence: re-suturing 0 1
PED-tarsorrhaphy 1 2Secondary glaucoma 2 12Cataract 1 4Graft infiltrate 2 4Endophthalmitis (at 12 months) 0 2
Graft rejection episodes-endothelial 0 27DALK-deep anterior lamellar keratoplasty,PK-penetrating keratoplasty, DM-descemet membrane, PED-persistant epithelial defect
Table-3: Complications noted in both the groups
ResultsParameter DALK PK
Endothelial rejection 0 17
Secondary glaucoma 0 3
Graft infiltrate 0 3
Endophthalmitis 0 2
Intra -operative micro perforation-postoperative DM detachment-C3F8
injection once-endothelial decompensation after cataract surgery
1 0
Poor ocular surface- sterile perforation 1 0
Postoperative DM detachment (C3F8
injected twice in one case)
2 0
DALK-deep anterior lamellar keratoplasty, PK-penetrating Keratoplasty, DM-descemet’s membrane, C3F8- perfluropropane Table-4, Causes of graft failure in the two groups
Slit image showing deposits in the deeper layers
Slit image showing double anteriorchamber
Slit image showing DM detachment superiorly
ASOCT showing double AC of the same patient seen above
Intradescemetic split leading to entrapment of air which was absorbed spontaneously
• Survival rate of the DALK group was 80% at 12 months and remained 70% at 24, 36, and 48 months.
• Survival rate of the PK group was 93%, 88%, 83%, 78%, 65%, 65%, and 52% at 12, 24, 36, 48, 72, 84, and 96 months, respectivelyKaplan-Meier Survival
plot
Literature Review
Study/year Indication
Eyes Micro perforation
Conversi-on to PK
Double AC
Sogutlu Sari E, et al./20131
MCD 35 10.7 % 14.6 % 2.8%
Kawashima M. et al./20062
MCD
10
20 %
14.6 % 40%
Present study/2014 MCD 21 24% 12.5% 43%
Reinhart WJ, et al./20103 ALL 1843
(MCD-17)
11.7 % 2.1 % 3.53%
PK: penetrating keratoplasty, AC: anterior chamber, MCD: macular corneal dystrophy
Table-5, Literature comparing intra and perioperative complication profile after DALK for MCD and other indications.
Conclusions• Visual and refractive outcomes are comparable between
DALK and PK with varying complication profiles
• Graft survival was better in the DALK group with time
compared with the PK group
• Surgical risk factors (DM perforation/Double AC) contribute
significantly to endothelial decompensation after DALK rather
than only the disease process in MCD
• DALK may be considered as an option in cases of MCD
where there is no direct clinical evidence of deposits on DM
• The main limitations of this retrospective study are the
difference in the number of cases, duration of follow up in
between the groups and also lack of endothelial cell density
References
1. Sogutlu Sari E, Kubaloglu A, Unal M, et al. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for macular corneal dystrophy: a randomized trial. Am J Ophthalmol. 2013; 156: 267-274.
2. Kawashima M, Kawakita T, Den S et al. Comparison of deep lamellar keratoplasty and penetrating keratoplasty for lattice and macular corneal dystrophies. Am J Ophthalmol. 2006;142 :304-9.
3. Reinhart WJ, Musch DC, Jacobs DS et al. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmology. 2011;118: 209-18.