Clinical Outcomes and Risk Factors for Graft Failure After Keratoplasty for Macular Corneal Dystrophy Jagadesh C. Reddy Somasheila I. Murthy, Prashant

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Clinical Outcomes and Risk Factors for Graft Failure After Keratoplasty for Macular Corneal Dystrophy

Clinical Outcomes and Risk Factors for Graft Failure After Keratoplasty for Macular Corneal DystrophyJagadesh 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 PurposeThe 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

MethodsStudy design: Retrospective review of clinical records of 104 patients with MCD who underwent corneal transplantation and followed up for at least 12 monthsStudy location: Cornea service, LV Prasad Eye Institute, IndiaStudy 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

Results

ParameterDALKPKNumber of eyes (patients) 21 (20) 109 (84) Mean age (SD, range) years30 (11.87, 5-50)34 (11.53, 18-65)Gender, male : female (%) 14:6 (70:30)48:36 (57:43)Laterality, RE:LE:BE 9:10:134:25:25Mean follow-up (SD, Range) in months 17 (8.80, 12-46 )43 (24.13, 12104)Mean donor size (SD)8.02 (0.28) mm8.11 (0.22) mmMean recipient size (SD)7.59 (0.24) mm 7.64 (0.23) mmDALK-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

Results

ParameterDALKPKP value*Mean pre-operative LogMAR BCVA (SD)1.09 (0.57)1.27 (0.61)0.22Mean Log MAR BCVA at 3 months (SD)0.58 (0.39)0.45 (0.51)0.52Mean Log MAR BCVA at 12 months (SD)0.43 (0.39)0.45 (0.51)0.89Mean Log MAR BCVA at final follow-up (SD)0.45 (0.59)0.56 (0.67)0.50Mean Refractive spherical equivalent at 12 months (SD)1.72 (3.08) D0.34 (3.98) D0.31Mean Refractive spherical equivalent at final follow-up (SD)0.72 (2.31) D-0.63 (3.68) D0.29Mean cylinder (median) at 12 months-3.25 (-3.5) D-3.30 (-3) D0.75Mean cylinder (median) at final follow-up-3.31 (-3) D-2.48 (2.62) D0.33DALK-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 usedTable-2 Comparison of visual and refractive results between the two groups

Results

ComplicationDALKPKIntraoperative : Conversion to PK3-DM micro perforation 5-Spontaneous expulsion of lens 01Post-operative Double anterior chamber 9-Wound leak: re-suturing 02Graft dehiscence: re-suturing01PED-tarsorrhaphy 12Secondary glaucoma 212Cataract14Graft infiltrate 24Endophthalmitis (at 12 months)02Graft rejection episodes-endothelial 027DALK-deep anterior lamellar keratoplasty,PK-penetrating keratoplasty, DM-descemet membrane, PED-persistant epithelial defect Table-3: Complications noted in both the groups

Results

ParameterDALKPKEndothelial rejection 017Secondary glaucoma 03Graft infiltrate 03Endophthalmitis 02Intra -operative micro perforation-postoperative DM detachment-C3F8 injection once-endothelial decompensation after cataract surgery 10Poor ocular surface- sterile perforation10Postoperative DM detachment (C3F8 injected twice in one case)20DALK-deep anterior lamellar keratoplasty, PK-penetrating Keratoplasty, DM-descemets membrane, C3F8- perfluropropane Table-4, Causes of graft failure in the two groups

Slit image showing deposits in the deeper layersSlit image showing double anteriorchamberSlit image showing DM detachment superiorlyASOCT showing double AC of the same patient seen aboveIntradescemetic 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 EyesMicro perforationConversi-on to PKDouble ACSogutlu Sari E, et al./20131MCD3510.7 %14.6 %2.8%Kawashima M. et al./20062MCD1020 %14.6 %40%Present study/2014 MCD2124%12.5%43%Reinhart WJ, et al./20103ALL1843(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.

ConclusionsVisual and refractive outcomes are comparable between DALK and PK with varying complication profilesGraft 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 DMThe 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

ReferencesSogutlu 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.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. 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.