Clinical Characteristics and Outcomes of Short-term Repeat Corneal Transplantation

Repeat corneal transplantation in Southern China: Indications, surgical technique, outcomes, and risk factors for repeat keratoplasty failure

PURPOSE

To report the indications, surgical techniques, and outcomes of repeat keratoplasty and evaluate the risk factors for graft failure in the Chinese population.

METHODS

The medical records of 216 patients (243 cases) who underwent at least two keratoplasties at a leading eye hospital in southern China between 2011 and 2020 were retrospectively reviewed. Indications and surgical procedures for repeat corneal transplantation were analyzed. Kaplan-Meier survival analysis was used to determine the graft survival rate after repeat keratoplasty. A multivariable survival model was used to assess the risk factors.

RESULTS

Repeated keratoplasties increased continuously from 2011 to 2020 (P = 0.002). The most common primary indication was infectious keratitis (38.7%), and the most common reason for repeat keratoplasty was graft rejection (30.04%). Regraft techniques included penetrating keratoplasty (PK) in 165 cases (67.9%), deep lamellar keratoplasty (DALK) in 52 cases (21.40%), and endothelial keratoplasty (EK) in 26 cases (10.7%). Median survival was 5.3, 6.8, and 6.4 years for PK, DALK, and EK, respectively. The 5-year survival rate was 53.5%, 66.6%, and 69.8% for PK, DALK, and EK, respectively. The median LogMAR visual acuity was 1.4 for PK, 0.75 for DALK, and 1.2 for EK at the end of the follow-up. Multivariate analysis revealed that graft rejection is a risk factor for repeat keratoplasty failure (P = 0.002).

CONCLUSIONS

DALK and EK may provide better outcomes than PK in treating graft failure. Preventing and treating postoperative graft rejection may be key to improving regraft survival. These findings will aid in the management of failed corneal grafts.

Local application of silver nitrate as an adjuvant treatment before deep lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment

Objective

The purpose of this study is to evaluate the efficacy and safety of the local application of silver nitrate (LASN) as an adjuvant treatment before deep lamellar keratoplasty (DLKP) for fungal keratitis responding poorly to medical treatment.

Methods

A total of 12 patients (12 eyes) with fungal keratitis responding poorly to medical treatment (for at least 2 weeks) were included. LASN was performed using 2% silver nitrate, the ulcer was cleaned and debrided, and then, the silver nitrate cotton stick was applied to the surface of the ulcer for a few seconds. The effect of LASN was recorded. The number of hyphae before and after treatment was determined by confocal microscope. After the condition of the ulcer improved, DLKP was performed. Fungal recurrence, best-corrected visual acuity (BCVA), loose sutures, and endothelial cell density (ECD) were recorded in detail.

Results

Clinical resolution of corneal infiltration and edema was observed, and the ulcer boundary became clear in all 12 patients after 7-9 days of LASN. Confocal microscopy showed that the number of hyphae was significantly reduced. Ocular pain peaked on days 1 and 2 after treatment, and 9 patients (75%, day 1) and 1 patient (8.3%, day 2) required oral pain medication. During the follow-up period after DLKP, no fungal recurrence and loose sutures were observed. After the operation, the BCVA of all patients improved. The mean corneal ECD was 2,166.83 ± 119.75 cells/mm2.

Conclusion

The LASN was safe and effective and can be well tolerated by patients. Eye pain can be relieved quickly. LASN as an adjuvant treatment before DLKP might be a promising therapeutic strategy.

Indications and Surgical Techniques for Repeat Corneal Transplantation in Eastern China: A Twelve-Year Study

Purpose

To analyze the indications and surgical procedures for repeat keratoplasty in eastern China from 2008 to 2019.

Methods

This retrospective descriptive study included 418 eyes of 411 patients who underwent no less than 2 keratoplasties at the Eye, Ear, Nose and Throat Hospital of Fudan University from 2008 to 2019. Medical charts were reviewed. The primary indications for repeat keratoplasty, the reasons for regrafting, and the surgical techniques used in the treatment were collected and analyzed.

Results

Among 418 eyes, 337 eyes (80.6%) had one repeat keratoplasty, and 81 eyes (19.4%) had multiple repeat keratoplasties (≥2 repeat keratoplasties). The median interval between the initial keratoplasty and the first repeat keratoplasty was 25 months, and that between two keratoplasties after the first repeat keratoplasty was 27.5 months. Infectious keratitis was the leading primary indication for single repeat keratoplasty (80 cases, 23.7%) and multiple repeat keratoplasties (19 cases, 23.5%). The second most common primary indication was bullous keratopathy for single repeat keratoplasty (49 eyes, 14.5%) and chemical injury for multiple repeat keratoplasties (14 eyes, 17.3%). The main reason for regrafting was allograft rejection (262 cases, 49.3%), followed by endothelial dysfunction (92 cases, 17.3%), and for vision improvement after tectonic keratoplasty (60 cases, 11.3%). Penetrating keratoplasty (PKP) was the major technique used in repeat keratoplasty (447 cases, 84.2%). However, Descemet stripping endothelial keratoplasty was more frequently used than PKP (72.4% vs. 27.6%, P < 0.001) in the treatment of failed endothelial keratoplasty.

Conclusion

Infectious keratitis was still the leading cause of repeat keratoplasty in eastern China. Although PKP remains the major technique of repeat keratoplasty, the application of customized lamellar keratoplasty has greatly expanded in the last decade. Cautious selection of indications, surgical techniques, and timing for surgery is crucial for a good prognosis after repeat keratoplasty.