Graft survival and endothelial outcomes in the new era of endothelial keratoplasty☆
Highlights
► Endothelial keratoplasty (EK) has rapidly evolved for treating endothelial disease. ► Surgical manipulation of donor EK tissue causes high early endothelial cell loss. ► Endothelial cell loss declines beyond 6 months after EK. ► The rate of primary or iatrogenic graft failure after EK averages 5%.
Introduction
The corneal endothelium is a delicate monolayer of neural crest-derived cells that maintains corneal deturgescence and transparency. The endothelial cells do not proliferate to any significant extent in vivo, and therefore diseases of the corneal endothelium frequently result in morbidity by causing poor vision and discomfort. Our understanding of corneal endothelial cell biology has been dramatically advanced by Nancy Joyce, PhD, and her laboratory, not least with their efforts to determine how to stimulate proliferation of the senescent endothelial cells.
Despite the advances in the basic science mechanisms pertaining to endothelial cell biology and disease, the current treatment of endothelial disease remains surgical. In 2010, 42,000 corneal transplants were performed in the United States, and over half of these were for endothelial disease (EBAA, 2010). For decades, penetrating (full-thickness) keratoplasty (PK) was the only procedure for endothelial replacement. PK was first reported by Eduard Zirm in 1906 (Zirm, 1989), and subsequently refined by Ramon Castroviejo (Castroviejo, 1931, Castroviejo, 1932a, Castroviejo, 1932b). Since the late 1990s, the surgical treatment of endothelial disease has rapidly evolved, with the current treatment of choice being endothelial keratoplasty (EK); in 2010, 19,000 EK procedures were performed in the United States (EBAA, 2010). EK is an intraocular procedure in which posterior host corneal layers are replaced by posterior donor corneal layers to restore endothelial function. The advent of EK has heralded new techniques, new challenges, new complications, and new uncertainties for long-term outcomes.
This review discusses endothelial keratoplasty techniques and how they pertain to the integrity of the corneal endothelium. Outcomes with respect to endothelial cell loss and graft survival will be discussed primarily.
Section snippets
Keratoplasty for endothelial disease
Knowledge of the surgical techniques for EK is important for understanding the factors that cause endothelial cell loss. The EK era has generated new questions about the resilience of the corneal endothelium to surgical trauma and the resulting long-term effects on graft survival.
Endothelial outcomes of keratoplasty
The success of corneal transplantation has traditionally been assessed by graft survival, which is the time to graft failure (Coster and Williams, 2005). Endothelial cell loss has also been frequently reported, although cell loss might not always indicate overall loss of endothelial function (Lass et al., 2010). Visual outcomes were difficult to assess in the era of PK, but are gaining more importance as EK predominates (Patel, 2011). Keratoplasty outcomes should be interpreted with caution,
Visual outcomes
The initial experience and results of DSEK have provided optimism for long-term graft survival and for the potential of restoring normal vision. The major advantages of EK over PK for vision are better uncorrected visual acuity and a predictable postoperative refractive error (Chen et al., 2008, Patel et al., 2009a, Price and Price, 2005). Although PK can provide a similar rate of visual recovery as DSEK (Patel et al., 2009a), visual recovery is considered to be quicker, and quality of vision
Future prospects for treating endothelial disease
Future treatments for endothelial disease would ideally avoid the need for surgery, and might include pharmacologic agents to stimulate endothelial cell proliferation (Joyce and Harris, 2010, Okumura et al., 2011, Okumura et al., 2009) or function (Hatou et al., 2010), or therapies to slow or halt disease progression. Until such novel therapies become available, keratoplasty will remain the mainstay of treatment, and efforts should continue to improve keratoplasty techniques and outcomes. Most
Role of the funding source
The funding sources had no involvement in the study design, collection, analysis and interpretation of data, in the writing of the report or in the decision to submit for publication.
Financial disclosure
None.
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