The long-term results of keratoplasty in eyes with a glaucoma drainage device

doi:10.1016/j.ajo.2004.02.058

American Journal of Ophthalmology

Volume 138, Issue 2, August 2004, Pages 200-205

This study was funded in part by an unrestricted grant to the Department of Ophthalmology at the University of California, Davis, from Research to Prevent Blindness, Inc., New York, New York.

https://doi.org/10.1016/j.ajo.2004.02.058 Get rights and content

Abstract

Purpose

To study the outcome of penetrating keratoplasty (PK) in eyes with a glaucoma drainage device (GDD).

Design

Retrospective case-controlled study.

Methods

We reviewed all patients who underwent PK from December 1986 to September 2002 at the University of California, Davis (n = 1,974). We identified 33 patients (40 grafts) who were treated with a GDD and followed up for 6 months or more after PK. Graft survival and glaucoma control were compared with grafts in patients without glaucoma (n = 40) and patients with medically controlled glaucoma (n = 17). Kaplan-Meier survival analysis, log rank test, repeated-measures analysis of variance (ANOVA), Fisher exact test, and χ² were used in group comparisons. Multivariate analysis was performed using the Cox proportional hazards model.

Results

The percentages of clear grafts in the glaucoma drainage device group were 58.5% and 25.8% at 1 and 2 years, respectively. At these time points, glaucoma was controlled in 74.0% and 63.1% of the eyes, respectively. Both medically controlled glaucoma patients and nonglaucomatous patients had higher graft survival percentages at comparable time points. The presence of a GDD was an important factor influencing graft survival (Hazard ratio = 6.8).

Conclusion

A GDD implant is an independent risk factor for graft failure. Although these devices are effective in controlling intraocular pressure (IOP) in the majority of eyes in the presence of PK, corneal graft clarity is often compromised.

Section snippets

Patients

Approval for the study was obtained from the Institutional Review Board at the University of California, Davis. We reviewed the charts of all patients diagnosed with glaucoma who underwent PK at our academic, tertiary-care center between December 1986 and September 2002 (n = 1,974). Infants and patients with developmental glaucoma were not selected. Patients who required the implantation of a GDD were considered together (GDD group). We excluded grafts with available follow-up data of less than

Results

The demographic characteristics of the subjects are described in Table 1. The groups had similar male to female ratios (P = .69) and eye involvement (P = .37). In most cases (24 patients, 72.7%), a Baerveldt implant was used. Molteno or Ahmed devices were implanted in seven (21.2%) and two (6.1%) patients, respectively. Most GDDs were implanted in the anterior chamber (81.8%); in six eyes (18.2%), a pars plana device was inserted. A total of 16 grafts of the GDD group (40%) were placed in eyes

Discussion

Glaucoma drainage devices are an effective way to control glaucoma when traditional medical and surgical methods are ineffective. Nevertheless, the presence of a GDD has been associated with a poorer long-term prognosis for corneal grafts.1, 2, 4, 5, 6 In our patients with a GDD, as in several previous series,2, 4, 6, 8, 9, 10, 11, 12 the percentage of clear grafts at 1 year (58.5%) and 2 years (25.8%) was low.

Ours is the first study to compare eyes with a GDD with eyes with both medically

Dr Lenio S. Alvarenga is a Research Fellow at the University of California, Davis, Department of Ophthalmology as well as a member of the External Eye Disease and Cornea Section of the Department of Ophthalmology, Federal University of Sao Paulo, Brazil. His primary research is in the areas of corneal transplantation, rehabilitation of patients with ocular surface disease, and ocular infections.

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Donor Corneal Endothelial Cell Maturity and Its Impact on Graft Survival in Glaucoma Patients Undergoing Corneal Transplantation
2024, American Journal of Ophthalmology
To examine corneal graft survival via corneal endothelial cell density (ECD) and corneal endothelial cell loss (ECL) at 5 years post-transplantation in the eyes of patients with and without a history of undergoing glaucoma surgery according to the maturity of the donor corneal endothelial cells.
Prospective cohort study.
This prospective cohort study included 17 patients with glaucoma and 51 patients without glaucoma who underwent Descemet's stripping automated endothelial keratoplasty or penetrating keratoplasty at the Baptist Eye Institute, Kyoto, Japan, between October 2014 and October 2016. Human corneal endothelial cells were cultured from residual peripheral donor cornea tissue, and the maturity of the cells was evaluated by cell surface markers (ie, CD166⁺, CD44^−/dull, CD24⁻, and CD105⁻) using fluorescence-activated cell sorting. Kaplan–Meier analysis or the chi-square test was used to assess the rate of successful corneal graft survival post-transplantation.
At 36 months postoperatively, the mean ECD and ECL in the glaucoma-bleb eyes were 1197 ± 352 cells/mm² and 55.5% ± 13.9% in the high-maturity group and 853 ± 430 cells/mm² and 67.7% ± 18.1% in the low-maturity group, respectively. Kaplan–Meier analysis revealed that at 5 years postoperatively, the overall rate of survival was 45%, that is, 100% in the high-maturity group and 25% in the low-maturity group (P < .05).
The findings in this prospective cohort study revealed that the use of donor corneal grafts containing mature-differentiated corneal endothelial cells could maintain the survival of the transplanted graft for a long-term period, even in patients with a history of undergoing glaucoma surgery.
Surgery for glaucoma in modern corneal graft procedures
2021, Survey of Ophthalmology
Citation Excerpt :
Good IOP control is also important for graft survival for eyes with previous glaucoma surgery.60 The most common glaucoma surgery reported with PKP in literature is GDD.4,8,16,34,66,130 In a recent study, comparing graft survival in eyes with GDD, graft failure occurs earlier in eyes with DSEK than PKP.
Glaucoma is a common cause of vision loss after corneal transplantion and is considered a major risk factor for graft failure. Glaucoma may be present before corneal transplant surgery, or increased intraocular pressure may develop after keratoplasty in up to one-third of patients. Pre-existing glaucoma should be controlled before keratoplasty, either medically or surgically. For postkeratoplasty increase in intraocular pressure; identifying the risk factors allows appropiate follow-up and management. Patients undergoing anterior lamellar keratoplasty may take advantage of reduced rates of postkeratoplasty glaucoma. Glaucoma also complicates eyes with endothelial keratoplasties, mostly related to management of intraocular pressure spikes derived from anterior chamber air bubbles. Nevertheless, the severity is less, and the intraocular pressure is more easily controlled when compared with penetrating keratoplasty. Adequate management of glaucoma that develops before or after keratoplasty may save eyes from irreversible damage to the optic nerve and increase graft survival.
Four-Year Survival of Descemet Membrane Endothelial Keratoplasty in Patients With Previous Glaucoma Surgery
2020, American Journal of Ophthalmology
To evaluate 4-year outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with previous glaucoma surgery.
Retrospective, comparative case series.
Patients with previous trabeculectomy or glaucoma drainage device (GDD) implantation who later underwent DMEK (study group) were matched for follow-up duration with Fuchs dystrophy DMEK patients (control group). The minimum follow-up was 18 months. Primary outcomes included graft survival and rejection rates, and secondary outcomes included rates of detachment/rebubble, endothelial cell loss, best spectacle-corrected visual acuity, intraocular pressure, and glaucoma medications/surgeries. Subgroup analysis compared eyes with and without a GDD.
Ninety-four eyes of 91 patients were included. There were 51 eyes of 49 patients in the study group (GDD = 32 eyes, no GDD = 19 eyes) and 43 eyes of 42 patients in the control group. The mean follow-up was 37.9 ± 15.2 and 33.8 ± 13.5 months, respectively (P = .322). Graft survival probability of the study group at 12, 24, 36, and 48 months was 75%, 60%, 43%, and 27%, respectively, compared with a consistent 88% in the control group (P < .001). Survival curves of study subgroups (GDD and no GDD) were significantly lower than the control group (P < .001). Rejection rates in the study and control groups were 19.6% and 2.3%, respectively (P = .010). Endothelial cell loss in the study group was 12%-22% higher than the control group at 12, 24, 36, and 48 months (P = .049, P = .027, P = .200, and P = .004).
In eyes with previous glaucoma surgery, DMEK has good early outcomes, but longer-term rejection and failure rates are high. Physicians and patients should be cognizant of the high likelihood of graft failure in this setting.
Surgical outcomes of endothelial keratoplasty safety-basket suture for management of difficult cases
2019, Canadian Journal of Ophthalmology
To report outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) safety-basket suture technique in complex eyes in which an air bubble could not be maintained in the anterior chamber.
Retrospective chart review.
Patient's undergoing DSAEK with use of the safety-basket suture technique in patients with corneal edema secondary to endothelial dysfunction with up to 3 years of follow-up between 2013 and 2016.
Outcome measures were corrected distance visual acuity, average endothelial cell count loss, graft decentration, graft detachment, rebubble rate, infection rate, graft rejection, and graft failure were analyzed.
The technique was used successfully for 36 high-risk cases with no incidence of graft decentration, postoperative infection, or graft rejection. Both the graft detachment and rebubble rate was found to be 11.1%. The graft failure rate was found to be 22.2% with an average of 3.3 months, with 37.5% of these being primary failure and 62.5% of these being secondary failure.
Endothelial keratoplasty safety-basket suture is a technique that can be beneficial in difficult DSAEK cases with a lower graft detachment rate compared with the current literature as well as a fairly low complication rate and graft failure while maintaining good visual outcomes. The safety-basket suture is the technique of choice for cases of aphakia and may allow for DSAEK in cases previously that may have only been considered for full-thickness keratoplasty.
Présenter les résultats de la technique de suture de type safety-basket dans les cas complexes de kératoplastie endothéliale automatisée de la membrane de Descemet (DSAEK, pour Descemet's stripping automated endothelial keratoplasty) lorsqu'il n’était pas possible de maintenir une bulle d'air en chambre antérieure.
Examen rétrospectif de dossiers médicaux.
Patients qui ont subi une DSAEK avec suture de type safety-basket en présence d'un œdème cornéen secondaire à un dysfonctionnement endothélial et qui ont bénéficié d'un suivi d'au plus 3 ans entre 2013 et 2016.
Les paramètres de mesure analysés comprenaient l'acuité visuelle corrigée de loin, la perte moyenne de densité cellulaire endothéliale, le décentrement du greffon, le décollement du greffon de même que les taux de réinjection postopératoire d'une bulle d'air (rebubbling), d'infection, de rejet du greffon et d’échec de la greffe.
La technique a été utilisée avec succès dans 36 cas à risque élevé sans qu'il se produise de décentrement du greffon, d'infection postopératoire ni de rejet de la greffe. Le taux de décollement du greffon et de réinjection postopératoire d'une bulle d'air se chiffrait à 11,1 %. Le taux d’échec de la greffe s’élevait à 22,2 %, après une moyenne de 3,3 mois; il s'agissait d'un échec primaire dans 37,5 % des cas et d'un échec secondaire dans 62,5 % des cas.
La kératoplastie endothéliale avec suture de type safety-basket peut être utile dans les cas complexes de DSAEK et peut réduire le taux de décollement du greffon comparativement à ce que l'on retrouve actuellement dans la littérature médicale; on note de plus un taux relativement faible de complication et d’échec de la greffe et le maintien de résultats visuels positifs. La suture de type safety-basket est la technique de choix en présence d'une aphakie et peut autoriser la DSAEK dans les cas où l'on n'aurait pu envisager que la kératoplastie de pleine épaisseur.
Three-year outcomes of Descemet's stripping endothelial keratoplasty in eyes with pre-existing glaucoma drainage devices
2019, Canadian Journal of Ophthalmology
Descemet's stripping endothelial keratoplasty (DSEK) is the most common procedure for corneal transplantation. The effect of a pre-existing glaucoma drainage device on long-term surgical outcomes is uncertain.
A retrospective chart review of all DSEK cases at an academic hospital over a 10-year period was conducted.
37 eyes who had undergone DSEK were included for analysis. These consist of 12 eyes with pre-existing GDD (GDD group), 13 eyes with glaucoma but no previous GDD (no-GDD group), and a control group of 12 patients with no ocular comorbidities apart from the indication for DSEK (control group). Visual acuity (VA) was significantly improved amongst all 3 groups, and there was no significant difference in VA between the GDD and no-GDD groups. There were no significant differences in absolute or increase in IOP between all three groups at 3 years. Graft survival rates of the 3 groups were not significantly different at 12 months. However, at 36 months, graft survival was 63% in the GDD group compared to 81% in the no-GDD group and 92% in the control group. In the GDD group, an increase in number of preoperative glaucoma drops, and a tube location in the anterior chamber were associated with an increased hazard ratio for failure.
Presence of a GDD adversely affects graft survival whereas glaucomatous eyes which were medically managed or surgically managed without a GDD had survival rates comparable to controls. Glaucoma-filtering surgeries may confer graft survival advantage over tube shunt surgeries after DSEK.
La kératoplastie endothéliale automatisée avec décapage de la Descemet (DSEK, pour Descemet's stripping endothelial keratoplasty) est la technique la plus fréquemment utilisée en vue d'une transplantation de la cornée. Cela dit, on ignore l'effet de la présence préalable d'un implant de drainage du glaucome (IDG) sur les résultats chirurgicaux à long terme.
Examen rétrospectif des dossiers médicaux de tous les cas de DSEK dans un hôpital universitaire sur une période de 10 ans.
Au total, 37 yeux qui avaient fait l'objet d'une DSEK ont été inclus dans cette analyse. Il s'agissait de 12 yeux ayant un IDG (groupe IDG), de 13 yeux glaucomateux sans IDG (groupe non-IDG) et d'un groupe témoin de 12 patients sans atteinte oculaire concomitante autre que l'indication d'une DSEK (groupe témoin). Il s'est produit une amélioration significative de l'acuité visuelle (AV) dans les 3 groupes, sans différence significative de l'AV entre les groupes IDG et non-IDG. On n'a enregistré aucune différence significative quant à la pression intraoculaire (PIO) absolue ou quant à l'augmentation de la PIO dans les 3 groupes à 3 ans. Les taux de survie du greffon dans les 3 groupes ne différaient pas de façon significative à 12 mois. Par contre, le taux de survie du greffon à 36 mois se chiffrait à 63 % dans le groupe IDG, comparativement à 81 % dans le groupe non-IDG et à 92 % dans le groupe témoin. Dans le groupe IDG, la hausse du nombre de collyres antiglaucomateux en période préopératoire et la localisation du tube de drainage dans la chambre antérieure étaient associées à une augmentation du rapport de risque d’échec.
La présence d'un IDG a des effets délétères sur la survie du greffon, tandis que la survie du greffon dans les yeux glaucomateux traités par un collyre ou ayant fait l'objet d'une chirurgie sans IDG était comparable à celle des témoins. Les chirurgies filtrantes s'accompagneraient d'une meilleure survie du greffon que l'implantation d'un tube de dérivation après une DSEK.
Clinical Outcomes of Descemet Membrane Endothelial Keratoplasty in Eyes With a Glaucoma Drainage Device
2019, American Journal of Ophthalmology
Citation Excerpt :
In the current study, the clinical outcomes of DMEK in eyes with a GDD were evaluated. While several research groups have reported outcomes of PK and DS(A)EK in eyes with a GDD, reports on DMEK are few, with small sample sizes and short-term follow-up (Table 4).3–12,18–26 In addition, for the available keratoplasty studies heterogeneity in study design—for example “mixed study groups” (shunt tube vs trabeculectomy vs trabeculectomy and shunt tube)—poses a challenge when interpreting results.
To evaluate the feasibility and clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with a glaucoma drainage device (GDD).
Retrospective, interventional case series.
Clinical outcomes of 23 DMEK procedures for bullous keratopathy (52%), failed previous transplant (39%), or Fuchs endothelial corneal dystrophy (9%) in 20 eyes (19 patients) with a GDD were retrospectively analyzed at 2 tertiary referral centers. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), postoperative complications, and graft survival.
Mean length of postoperative follow-up after DMEK was 19 (±17) months. Kaplan-Meier survival analysis showed an 89% cumulative graft success rate at 1 year postoperatively. At 1 year postoperatively (n = 15 eyes), BCVA improved by ≥2 Snellen lines in 11 eyes (73%) and remained stable in 4 eyes (27%). Donor ECD decreased by 37% (n = 14), 60% (n = 11), and 71% (n = 11) at 1, 6, and 12 months postoperatively, respectively. Postoperative complications up to 2 years postoperatively comprised pupillary block in 1 eye (successfully reversed by partial air removal), visually significant graft detachment requiring rebubbling in 5 eyes (22%), allograft rejection successfully reversed with topical steroids in 2 eyes (9%), secondary graft failure in 2 eyes (9%), and cataract in 1 of 3 phakic eyes (33%). Re-keratoplasty was required in 2 eyes (9%).
With specific surgical modifications, DMEK provided acceptable clinical outcomes when taking the complexity of these eyes into account. However, presence of a GDD may reduce graft survival times and may pose a risk for more frequent regrafting.

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Dr. Mark J. Mannis is Professor and Chair of the Department of Ophthalmology at the University of California, Davis. His primary research includes studies in corneal transplantation, the development of new antimicrobial agents, and visual function in corneal disease. He is also one of the co-principal investigators of the Cornea Donor Study and the author offive textbooks. Clinically, he specializes in corneal and refractive surgery and diseases of the external eye.

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Original articleThe long-term results of keratoplasty in eyes with a glaucoma drainage device☆

Abstract

Purpose

Design

Methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

Surv Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Original article
The long-term results of keratoplasty in eyes with a glaucoma drainage device☆