Incidence and Risk Factors of Ocular Hypertension/Glaucoma After Descemet Stripping Automated Endothelial Keratoplasty

Impact of postoperative intraocular pressure elevation on graft endothelial cells in non-preexisting glaucoma eyes undergoing descemet membrane endothelial keratoplasty: a cohort study

BACKGROUND

Descemet membrane endothelial keratoplasty (DMEK) has become the dominant keratoplasty procedure. However, the impact of high intraocular pressure (IOP) on the DMEK prognosis in patients without preexisting glaucoma remains unknown.

METHODS

Non-glaucoma patients who underwent DMEK in Peking University Third Hospital between July 2017 and March 2023 with a follow-up duration longer than six months were included in this cohort study. Eyes were divided into three groups: Group A) normal IOP; Group B) early IOP elevation (IOP ≥ 30 mmHg or increase of more than 10 mmHg from baseline within 3 days); Group C) intermediate-term IOP elevation (IOP > 21 mmHg or increase of more than 10 mmHg from baseline after 14 days postoperatively). The postoperative IOP, endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and rate of graft failure were analysed.

RESULTS

Forty-seven eyes from forty-seven patients were included. Thirty-seven eyes were bullous keratopathy, and ten were Fuchs endothelial corneal dystrophy. Twenty-five eyes were classified as Group A, six as Group B and sixteen as Group C. The mean peak IOP was 49.00 ± 4.99 mmHg in Group B eyes and 31.89 ± 11.75 mmHg in Group C eyes. The postoperative BCVA significantly differed from that before surgery (P < 0.001). The ECD at 3 months after surgery in eyes with intermediate-term IOP elevation was lower (P = 0.032). Four eyes with intermediate-term IOP elevation developed graft failure (P = 0.001).

CONCLUSIONS

Intermediate-term IOP elevation after DMEK may reduce the graft ECD and lead to graft failure within six months after surgery. However, early IOP elevation had no effect on the prognosis. Careful IOP monitoring and intermediate-term IOP management should be conducted for graft protection.

Non-Descemet stripping endothelial keratoplasty for bullous keratopathy in patients with atopic dermatitis: A long-term case report

RATIONALE

Patients with atopic dermatitis undergoing penetrating keratoplasty (PKP) face a high risk of postoperative complications. Endothelial keratoplasty may be a safer alternative for such patients, including those with abnormal anterior chamber anatomy.

PATIENT CONCERNS

3 male patients, aged 33 to 44, presented with blurred vision at Keio University Hospital.

DIAGNOSIS

Bullous keratopathy was diagnosed through slit-lamp examination and specular microscopy. Two patients had well-controlled systemic atopic dermatitis, while 1 had blepharitis associated with atopic dermatitis. Two patients had peripheral anterior synechia, and 2 had undergone glaucoma surgery before keratoplasty.

INTERVENTIONS

Non-Descemet stripping endothelial keratoplasty (nDSAEK) was performed by a single surgeon.

OUTCOMES

The best-corrected visual acuity ranged from 0.7 to 1.5 logMAR before surgery and from 0.2 to 2.3 logMAR after surgery. One year post-surgery, the graft remained clear in 2 cases; however, in the case of repeated glaucoma surgeries after nDSAEK, the graft became edematous. Corneal endothelial cell density was 1586 and 1988 cells/mm² in 2 cases and undetectable in the failed case. The follow-up period ranged from 2.5 to 9 years.

LESSONS

Despite the presence of peripheral anterior synechia or prior glaucoma surgery, some patients experienced a favorable long-term postoperative course following nDSAEK. This procedure may offer a safer alternative for treating patients with atopic dermatitis who have ocular complications that present a high risk for PKP.

Risk Factors for Glaucoma and Ocular Hypertension and Post-Transplant Complications in Keratoconus: A Multivariable Analysis

Background: The purpose of this study was to investigate the risk factors for glaucoma in patients with keratoconus following keratoplasty and to identify potential factors that could affect post-transplant complications. Methods: A retrospective analysis was conducted on the medical records of 192 keratoconus patients who underwent keratoplasty. Data on treatment history, perioperative information, tissue bank data, postoperative regimens, complications, and infections were collected and analyzed. Statistical analysis was performed to identify risk factors associated with glaucoma and transplant complications. Results: There was a 41.6% incidence of glaucoma (high IOP) (p < 0.001), with the median time to glaucoma development being 314 ± 67 days post-transplant. A significant number of patients required surgical intervention, accounting for 48.05%. Our analysis revealed a 14% graft failure rate. On univariable Cox proportional hazard analysis, the following factors demonstrated statistically significant associations with the risk of glaucoma after transplantation: donor endothelial cell density, the use of a single continuous suture type, and the surgeon (performing the surgery). For many variables, the only factor that remained significant was the surgeon. Among the factors analyzed for risks of failure post-transplantation, significant associations were observed for the donor age, the time from harvest to transplant, and the surgeon. In the multivariable analysis, donor age emerged as a significant predictor of post-transplant complications. Conclusions: Risk factors such as donor endothelial cell density, suture type, surgeon, host and donor size, and host gender were found to increase the risk of developing glaucoma post-keratoplasty. Surgeon type was identified as a significant risk factor, while donor age was predictive of post-transplant complications.

Intraocular pressure measurement and association with corneal biomechanics in patients underwent Descemet's stripping with endothelial keratoplasty: a comparative study

Purpose

To compare corneal biomechanical properties and intraocular pressure (IOP) measurements in patients who underwent Descemet's stripping with endothelial keratoplasty (DSEK) with those of the follow healthy eyes.

Methods

In this retrospective comparative study, a total of 35 eyes of 35 patients who underwent DSEK by a single surgeon from 2015.02 to 2019.12 were enrolled along with their fellow healthy eyes. Corneal biomechanical parameters were assessed at least 3 months post-DSEK using Corneal Visualization Scheimpflug Technology (CST). IOP was measured by CST, Goldmann applanation tonometry (GAT), and MacKay-Marg tonometer.

Results

Central corneal thickness (CCT) and stiffness parameter at first applanation (SP-A1) were significantly increased after DSEK when compared to the fellow eyes. In DSEK eyes, biomechanically-corrected intraocular pressure (bIOP) and MacKay-Marg IOP correlated significantly with GAT IOP measurements, with bIOP showed the lowest IOP values. All the IOP values did not correlate with CCT. However, GAT-IOP and MacKay-Marg IOP showed a positive correlation with SP-A1.

Conclusion

The corneal stiffness increased after DSEK. Central corneal thickness may have less influence than corneal biomechanics on IOP measurements in eyes after DSEK. Biomechanically-corrected IOP obtained by CST seemed to be lower than other tonometry techniques in DSEK eyes, perhaps because of correction for corneal stiffness, CCT and age.

Changes in the Visual Field Test after Descemet Stripping Automated Endothelial Keratoplasty in Advanced Glaucoma

Background: To evaluate changes in the visual field (VF) after Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with advanced glaucoma and previous trabeculectomy. Methods: Changes in VF, best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of glaucoma medications were analyzed before and after DSAEK in 19 eyes. The VFs were evaluated using the 10-2 program of the Humphrey Field Analyzer (HFA) and/or Goldmann perimetry (GP). Results: In nine eyes, the MD improved from -22.24 ± 6.5 dB to -18.36 ± 5.1 dB in HFA. In five out of nine eyes, postoperative MD improved >1 dB compared to preoperative MD. In GP testing, 10 out of 15 eyes showed an improvement, that is, greater than 20° in VF enlargement by the isopter of I-4e and/or new detection of a smaller or darker isopter. Overall, improvement in VF with the HFA and/or GP test was observed in 12/19 (63.2%) eyes after DSAEK. Postoperative BCVA improved by more than two lines in logMAR VA in 18 of 19 (94.7%) eyes. There were no significant differences between the preoperative and postoperative IOP and the number of glaucoma medications. Conclusions: DSAEK may produce subjective improvement in the visual field as well as improved visual acuity, even in advanced glaucomatous eyes.

Outcomes of XEN Stent in Patients With Glaucoma and Previous Corneal Transplantation

PRCIS

The XEN stent safely and effectively controls intraocular pressure in select patients with history of corneal transplantation.

PURPOSE

Glaucoma is a common complication after corneal transplantation and can be difficult to manage in these patients. This study reports outcomes of XEN stent implantation in eyes with glaucoma in the setting of previous corneal transplantation.

PATIENTS AND METHODS

Noncomparative retrospective case series including eyes with a history of corneal transplantation and subsequent XEN stent implantation by a single glaucoma surgeon in Surrey, British Columbia, between 2017 and 2022. The analysis included patient demographics, pre and postoperative intraocular pressure (IOP), pre and postoperative glaucoma medications, peri and postoperative complications and interventions, and incidence of repeat corneal transplantation and additional glaucoma procedures to control IOP.

RESULTS

Fourteen eyes with previous cornea transplantation underwent XEN stent implantation. Mean age was 70.1 years (range: 47-85 y). Mean follow-up was 18.2 months (range: 1.5-52 mo). The most common glaucoma diagnosis was secondary open angle glaucoma (50.0%). There was a significant reduction in IOP and the number of glaucoma agents at all postoperative time points ( P < 0.05). IOP decreased from 32.7 ± 10.0 mm Hg at baseline to 12.5 ± 4.7 mm Hg at the most recent follow-up. Glaucoma agents decreased from 4.0 ± 0.7 to 0.4 ± 1.0. Two eyes required additional glaucoma surgery to control IOP, with an average time to reoperation of 7 weeks. Two eyes underwent repeat corneal transplantation, with an average time to reoperation of 23.5 months.

CONCLUSIONS

In selected patients with previous corneal transplants and refractory glaucoma, the XEN stent was safely implanted and effectively reduced IOP in the short term.

Complications of Descemet stripping endothelial keratoplasty - A retrospective interventional study at a tertiary eye care center in Southern India

Purpose

To analyze the visual outcome and complications of Descemet stripping endothelial keratoplasty (DSEK) with their management in 256 eyes at a tertiary eye care center in southern India.

Methods

This is a retrospective interventional study of 62 months duration conducted at a tertiary eye care center in southern India. Two hundred and fifty-six eyes of 205 patients were included in the study after obtaining written informed consent from the patients. All cases of DSEK were performed by a single experienced surgeon. In all cases, donor dissection was performed manually. A Sheet's glide was inserted through the temporal corneal incision and donor button was placed on the Sheet's glide with the endothelial side down. The lenticule was separated and inserted into the anterior chamber by pushing the lenticule into the anterior chamber using Sinskey's hook. Any complication, either intraoperative or postoperative, was recorded and managed either medically or by appropriate surgical means.

Results

The mean best corrected visual acuity (BCVA) before surgery was CF-1 m, which improved to 6/18 after surgery. Intraoperative donor graft perforation during dissection was seen in 12 cases, thin lenticule in three eyes, and repeated artificial Anterior Chamber (AC) collapse in three eyes. Dislocation of lenticule was the most common complication seen in 21 eyes, which was managed by graft repositioning and rebubbling. Eleven cases had minimal separation of the graft and seven cases had interface haze. Pupillary block glaucoma was seen in two cases that resolved with partial release of bubble. Surface infiltrate was seen in two cases, which was managed with topical antimicrobial agents. Primary graft failure was seen in two cases.

Conclusion

DSEK is a promising alternative to penetrating keratoplasty for corneal endothelial decompensation, but it also has its own merits and limitations, and most often, merits overweigh limitations.

Determinants of Glaucoma Therapy Escalation After Descemet-Stripping Automated Endothelial Keratoplasty To Treat Pseudophakic Bullous Keratopathy: A Nested Case-Control Study

Purpose:

To study the determinants of glaucoma therapy escalation (GTE) after Descemet-stripping automated endothelial keratoplasty (DSAEK) for pseudophakic bullous keratopathy in an eye-care hospital in Saudi Arabia.

Methods:

This nested case-control study evaluated patients who required medical or surgical treatment for controlling glaucoma after DSAEK (defined as GTE; GTE group). A group of patients who did not require any intervention post-DSAEK served as controls (control group). Data were collected on preoperative, intraoperative, and postoperative parameters for DSAEK. Variables were compared between groups to evaluate risk factors for GTE and graft failure.

Results:

The study sample comprised 117 eyes (40 in the GTE group and 77 in the control group). Glaucoma was present in 20 (17.1%) of the eyes before DSAEK. The median duration of follow-up was 27 months [Interquartile range (IQR): 24; 42]. Intraoperative complications occurred in 4 eyes, and 2 eyes had a decentered donor button. Graft failure causing vision impairment and GTE at the final follow-up were noted in 19 (16.2%) and 40 (34.2%) eyes, respectively. Glaucoma prior to DSAEK was significantly associated with GTE [odds ratio (OR) = 6.4; 95% confidence interval (CI) 2.4; 18.3; P = 0.0004]. A history of penetrating keratoplasty (PK) was significantly associated with GTE after DSAEK [OR = 6.2 (95% CI 1.5; 24.7) P = 0.008]. At the last visit, GTE and graft failure were positively associated (OR = 27.2, P < 0.005).

Conclusion:

Escalation of glaucoma therapy was warranted in one in 3 eyes that had undergone DSAEK. GTE and graft failure are interrelated complications. Patients with glaucoma and PK have a higher risk of GTE post-DSAEK.