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.