Elsevier

Ophthalmology

Volume 119, Issue 10, October 2012, Pages 1982-1987
Ophthalmology

Original article
Descemet's Stripping Endothelial Keratoplasty: Long-term Graft Survival and Risk Factors for Failure in Eyes with Preexisting Glaucoma

https://doi.org/10.1016/j.ophtha.2012.04.031Get rights and content

Purpose

To evaluate long-term corneal graft survival and risk factors for graft failure after Descemet's stripping endothelial keratoplasty (DSEK) in eyes with preexisting glaucoma.

Design

Retrospective case control study.

Participants

A total of 835 DSEK cases performed by a single surgeon between December 2003 and August 2007 were reviewed. Only the first treated eye of each patient with at least 1 year follow-up was included, resulting in 453 cases; 342 had no prior glaucoma (C), 65 had medically managed preexisting glaucoma (G), and 46 had prior glaucoma surgery (GS).

Methods

Corneal graft failure was defined as persistent corneal edema resulting in irreversible loss of optical clarity. Corneal graft survival in the 3 groups was calculated using Kaplan–Meier survival analysis. Nine potential risk factors for graft failure were evaluated by Cox proportional hazards univariate and multivariate analysis. These methods took length of follow-up into consideration.

Main Outcome Measures

Corneal graft survival and risk factors influencing long-term corneal endothelial failure.

Results

The 1-, 2-, 3-, 4-, and 5-year graft survival was 99%, 99%, 97%, 97%, and 96%, respectively, in group C; 100%, 98%, 98%, 96%, and 90%, respectively, in group G; and 96%, 91%, 84%, 69%, and 48%, respectively, in group GS (P < 0.001). In the GS group, the 5-year survival rate for eyes with a glaucoma drainage device (GDD) and those with trabeculectomy only was 25% and 59%, respectively. Indication for DSEK, surgically managed glaucoma, type and number of prior glaucoma surgeries, and occurrence of a rejection episode were the significant risk factors for graft survival in univariate analysis. Several factors were correlated; in a multivariate model, prior glaucoma surgery (P < 0.0001) and a prior rejection episode (0.0023) were the significant risk factors for corneal endothelial failure.

Conclusions

Patients with medically managed glaucoma had significantly better 5-year graft survival than those with surgically managed glaucoma. A prior glaucoma shunt or trabeculectomy significantly increased the risk of DSEK endothelial failure.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Materials and Methods

In this institutional review board–approved study, 835 DSEK cases performed between December 2003 and August 2007 at Price Vision Group (Indianapolis, IN) were retrospectively reviewed. All patients read and signed an informed consent document for the transplant procedure, as well as an informed consent document allowing their medical information to be used for research purposes. The study was conducted in accordance with good clinical practices, the Declaration of Helsinki, and the Health

Results

On the basis of the inclusion and exclusion criteria, 453 eyes qualified for the study; 348 eyes were classified as a group without preexisting glaucoma (C), 65 eyes had medically managed glaucoma (G), and 46 eyes had surgically managed glaucoma (GS). Overall, the cases that qualified for the study did not differ significantly in key characteristics from cases that did not qualify because of lack of at least 1 year follow-up (P > 0.05). The mean follow-up duration was 4 years (range, 1–7 years).

Discussion

This study reports for the first time the long-term corneal graft survival and risk factors for graft survival in eyes with preexisting glaucoma in a large DSEK cohort. The 5-year graft survival was significantly lower in eyes with prior glaucoma surgery, especially so in eyes with preexisting GDD. In a multivariate model evaluating potential risk factors for graft survival, prior glaucoma surgery (P < 0.0001), and occurrence of a rejection episode (P = 0.0023) were significant risk factors for

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      Race was not found to be a risk factor for graft rejection after DSAEK in the Cornea Preservation Time Study2; however, most study participants (90.2%) were White. Furthermore, many of these studies have small sample sizes that limit the ability to adjust for surgical indication and ocular comorbidities such as glaucoma, which are known to impact graft survival.16,17 The current IRIS Registry analysis adjusted for many factors known to affect graft survival after EK, including the EK indication, ocular comorbidities, and postoperative complications.

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    Manuscript no. 2012-157.

    Financial Disclosure(s): The author(s) have made the following disclosure(s): Marianne O. Price and Francis W. Price received a travel grant from Moria. Arundhati Anshu has no conflict of interest to disclose.

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