Outcome of Graft Central Thickness After Penetrating Keratoplasty

doi:10.1016/j.ophtha.2004.11.044

Ophthalmology

Volume 112, Issue 4, April 2005, Pages 626-633

https://doi.org/10.1016/j.ophtha.2004.11.044 Get rights and content

Objective

To analyze the outcome of graft central thickness after penetrating keratoplasty.

Design

Retrospective observational cohort study.

Participants

Eight hundred fifty-six consecutive penetrating keratoplasties (772 patients) performed between 1992 and 2001 were analyzed and 772 were included (1 graft per patient was included).

Methods

Slit-lamp examination and ultrasound pachymetry.

Main Outcome Measures

Slit-lamp findings, intraocular pressure, and graft central thickness were recorded.

Results

Patients were observed for an average of 55 months. The 36- and 60-month graft survival estimates were, respectively, 77.2% and 71.0%. The average graft central thickness in successful transplants was 655 μm at 1 week, 558 μm at 1 month, 533 μm at 6 months, 538 μm at 12 months, 558 μm at 24 months, 561 μm at 36 months, and 568 μm at 5 years. At each postoperative time point, the percentage of eyes with decreased, normal, and increased graft central thickness was significantly different according to slit-lamp findings. Of the patients with increased graft thickness, 46.2% had a simple outcome (normal intraocular pressure and normal slit-lamp findings), 28.6% experienced rejection, 15.8% experienced a graft nonimmunological event, and 9.4% experienced increased intraocular pressure. At each postoperative follow-up, subsequent graft survival was significantly lower in patients with increased graft thickness as compared with patients with normal or decreased graft thickness. When analyzing only patients with simple outcome, the relative risk of graft failure was 3.3 if graft thickness was increased at 1 month (P<0.0001).

Conclusions

In conclusion, graft central thickness assessed by ultrasound pachymetry is a useful method for observing patients who have undergone penetrating keratoplasty. Even when slit-lamp examination reveals no complications, patients with an increase in graft thickness above the upper limit of normal for the postoperative time point under consideration are at greater risk of failure.

Section snippets

Study Design

We studied 856 consecutive penetrating keratoplasties carried out in 772 patients between December, 1992, and May, 2001. Eighty-four of 772 patients (9.8%) received 2 grafts in the same or contralateral eye during the study period. Because these were not independent observations, we analyzed our data, including only the first graft performed during the study period, for these 84 patients. Thus, 772 penetrating keratoplasty procedures performed in 772 patients were included in the present study.

Results

The 36- and 60-month graft survival estimates were, respectively, 77.2% and 71.0% (Fig 1). The average normal value of graft central thickness and its 95% confidence interval in successful transplants, according to postoperative time point, are shown in Figure 2 and Table 2. Graft central thickness significantly decreased between 1 and 2 weeks, between 2 weeks and 1 month, and between 1 and 3 months. It significantly increased between 12, 18, and 24 months and between 36 months and 4 years,

Discussion

Because of the high number of eyes included in this study, the normal limits of graft central thickness could be calculated at each postoperative time point after verifying that graft thickness was distributed normally in uncomplicated corneal transplants. Variability of graft central thickness was not important after the first 2 postoperative weeks, because the coefficient of variation of this measure was less than 10% at each postoperative time point.

In this series of penetrating

References (20)

J.H. Lass et al.
Comparison of corneal storage in K-Sol and chondroitin sulfate corneal storage medium in human corneal transplantation
Ophthalmology
(1989)
J.H. Lass et al.
An in vitro and clinical comparison of corneal storage with chondroitin sulfate corneal storage medium with and without dextran
Ophthalmology
(1990)
R.L. Lindstrom et al.
Optisol corneal storage medium
Am J Ophthalmol
(1992)
W.M. Bourne
One-year observation of transplanted human corneal endothelium
Ophthalmology
(1980)
J.H. Lass et al.
Epidermal growth factor and insulin use in corneal preservationResults of a multi-center trial
Ophthalmology
(1994)
W.M. Bourne et al.
Corneal endothelium five years after transplantation
Am J Ophthalmol
(1994)
J.J. Ing et al.
Ten-year postoperative results of penetrating keratoplasty
Ophthalmology
(1998)
O. Touzeau et al.
Précision et fiabilité de la pachymétrie Orbscan et ultrasonique
J Fr Ophtalmol
(2001)
L. Modis et al.
Scanning-slit and specular microscopic pachymetry in comparison with ultrasonic determination of corneal thickness
Cornea
(2001)
M.J. Giraldez Fernandez et al.
A comparison of two pachymetric systems: slit-scanning and ultrasonic
CLAO J
(2002)

There are more references available in the full text version of this article.

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Management of recurrent acute bilateral corneal endotheliitis monitored by serial corneal pachymetry
2016, Medical Journal Armed Forces India
Incidence of Intraocular Pressure Elevation and Glaucoma after Lamellar versus Full-Thickness Penetrating Keratoplasty
2016, Ophthalmology
Citation Excerpt :
We chose a relatively high threshold of 24 mmHg for noting postoperative IOP elevation. Because corneal central thickness usually is elevated after keratoplasty, the IOP determined via applanation may be overestimated.28 Limitations of this study include its retrospective design and absence of randomization.
To analyze the cumulated incidence of glaucoma after penetrating keratoplasty (PK), anterior lamellar keratoplasty (ALK), and endothelial keratoplasty (EK).
Cohort study. Data were recorded prospectively and analyzed retrospectively.
A total of 1657 consecutive eyes of 1657 patients undergoing corneal transplantation between 1992 and 2013.
Penetrating keratoplasty (date range, 1992–2013), ALK (date range, 2002–2013), and Descemet's stripping automated EK (date range, 2006–2013).
Postoperative intraocular pressure (IOP), glaucoma treatments, and glaucoma-related loss of vision (loss of central visual function resulting in absence of light perception or light perception limited to the temporal visual field). Cox proportional hazard regression model was used to analyze risk factors for glaucoma after keratoplasty.
The 10-year cumulated incidence of elevated IOP and elevated IOP requiring treatment was 46.5% and 38.7%, respectively. In multivariate analysis, 4 variables were significantly associated with a higher incidence of elevated IOP requiring treatment after keratoplasty: preoperative glaucoma or IOP >20 mmHg (adjusted hazard ratio [HR], 1.56; P < 0.001), penetrating keratoplasty (PK) (adjusted HR, 1.12 vs. ALK and 1.10 vs. EK; P < 0.001), postoperative lens status (adjusted HR vs. phakic eyes: 1.15 for posterior chamber intraocular lens, 1.43 for anterior chamber intraocular lens [IOL], 2.83 for aphakic eyes; P < 0.001), and IOL exchange or removal during surgery (adjusted HR, 1.48; P < 0.001). Recipient age, preoperative diagnosis, filtering surgery before keratoplasty, vitrectomy associated with keratoplasty, and filtering surgery associated with keratoplasty were significantly associated with a higher incidence of elevated IOP requiring treatment after keratoplasty in univariate analysis but not in multivariate analysis. The 10-year probability of loss of vision related to glaucoma was 1.0% after EK, 2.1% after ALK, and 3.6% after PK (P = 0.036).
The incidence of elevation of IOP after keratoplasty and development of glaucoma are significantly decreased with ALK and EK compared with PK. We believe this is due to diminished surgery-induced damage to the anterior chamber angle and trabecular meshwork, and reduced postoperative use of steroids.
Long-term rejection incidence and reversibility after penetrating and lamellar keratoplasty
2013, American Journal of Ophthalmology
Citation Excerpt :
This finding may show that decreased amount of grafted tissue may induce weaker immune response. It seems of major interest to measure graft thickness during rejection episodes.36 Our study shows that outcome of rejection episodes is influenced by the change in central corneal thickness between the time of presentation and the previous examination: rejection irreversibility was higher when the change in central corneal thickness was high (ie, >150 μm).
To identify risk factors for corneal graft rejection and rejection irreversibility.
Retrospective cohort study.
setting: Institutional. patients: A total of 1438 consecutive eyes of 1438 patients who underwent corneal transplantation for optical indication at the Centre Hospitalier National d’Ophtalmologie des XV-XX, Paris, France, between December 1992 and December 2010 were studied. Surgical technique was penetrating keratoplasty (PK) in 1209 cases, anterior lamellar keratoplasty (ALK) in 165 cases, and Descemet stripping with endothelial keratoplasty in 64 cases. main outcome measures: Cumulative incidence of rejection episodes and rejection irreversibility rate.
A total of 299 cases of rejection episodes were identified, of which 145 (48.5%) were irreversible after treatment. In multivariate analysis, the cumulative incidence of rejection episodes was influenced by recipient age (P = .00002), recipient rejection risk (P = .0003), lens status (P = .00003), and surgical group (P = .035). A higher incidence of rejection episodes was observed in young patients (<20 years) and patients aged from 41 to 50, high-risk recipients, aphakic eyes and eyes with anterior chamber intraocular lens, and eyes with PK (compared with eyes with ALK). Rejection episodes were more likely to be irreversible for high-risk recipients (P = .02), for eyes with preoperative hypertony (P = .009), and for eyes with poor visual acuity at presentation (P = .002).
Recipient rejection risk and surgical group are the main risk factors for rejection as they both influence the incidence of rejection and the reversibility rate. Recipient age and lens status are predictive factors for the occurrence of rejection. Preoperative hypertony is a predictive factor for rejection irreversibility.
Rejection of corneal allografts
2011, Journal Francais d'Ophtalmologie
Le rejet d’allogreffe de cornée est la première cause d’échec des kératoplasties transfixiantes. C’est un processus immunologique complexe au cours duquel la reconnaissance d’allo-antigènes du greffon par le système immunitaire de l’hôte entraine une réponse immunitaire dirigée contre le greffon. Il peut toucher les différentes couches de la cornée, le rejet endothélial étant la forme la plus grave. Dans certains cas, le rejet mènera à l’échec définitif de la greffe. De nombreux facteurs de risque liés au donneur ou au receveur favorisent la survenue d’un épisode de rejet. La corticothérapie, par voie topique, locorégionale ou générale selon les cas, est le traitement préventif et curatif de référence du rejet. D’autres traitements immunosuppresseurs sont prometteurs mais demandent une évaluation plus précise. La détection précoce du rejet est essentielle, permettant d’instaurer rapidement un traitement agressif, et donc de diminuer le risque d’échec définitif de greffe, notamment par perte d’un nombre trop important de cellules endothéliales. La prévention du rejet repose aussi sur la compatibilité tissulaire entre donneur et receveur. La compatibilité ABO chez les patients à haut risque permet une diminution du risque de rejet. Une compatibilité HLA pourrait également avoir un intérêt dans certaines indications.
Corneal graft rejection is the major cause of penetrating keratoplasty failure. It is a complex immunological process that involves recognition of alloantigens from the corneal graft by the host's immune system, leading to an efferent immune response against the graft. Each layer of the cornea can undergo rejection, endothelial rejection being the most severe form. In some cases, rejection will lead to corneal graft failure. Many donor- and host-related risk factors contribute to corneal graft rejection. Corticosteroid therapy, topical or systemic, is the gold-standard in the preventive and curative treatment of rejection. Other immunosuppressive agents are promising but require further evaluation. Early detection of rejection is essential to establish an aggressive treatment and reduce the risk of graft failure. Prevention of rejection is also based on tissue matching between donor and recipient. In high-risk patients, ABO compatibility decreases the risk of rejection. HLA compatibility could positively influence corneal graft survival in some cases.
Phacoemulsification and customized toric intraocular lens implantation in eyes with cataract and high astigmatism after penetrating keratoplasty
2011, Journal of Cataract and Refractive Surgery
Citation Excerpt :
However, endothelial failure remains a worrisome complication of this procedure.10,11 An accurate preoperative examination of corneal graft endothelium and thickness is mandatory to counsel patients regarding this risk.12,13 An alternative approach to correct cataract and high astigmatism after PKP is phacoemulsification and implantation of a monofocal IOL, followed by a keratorefractive procedure.
Phacoemulsification and implantation of a hydrophilic acrylic toric intraocular lens (IOL) (T-flex 623T) with customized cylindrical power was performed in 1 eye in 3 consecutive patients with cataract and high postkeratoplasty astigmatism (range 6.75 to 8.75 diopters [D]). Twelve months postoperatively, the uncorrected distance visual acuity improved from 20/200 to 20/30 in Case 1, from 20/400 to 20/40 in Case 2, and from 20/200 to 20/25 in Case 3 and the corrected distance visual acuity was 20/25 or better in all 3 eyes. The spheroequivalent was within ±0.50 D of the intended value and the refractive astigmatism was less than 1.00 D. The corneal grafts were transparent, and the endothelial cell loss range was 6% to 12%. Rotation of the toric IOL was less than 5 degrees. The toric IOL with customized cylindrical power provided good postoperative rotational stability and very satisfactory postoperative visual recovery. This type of toric IOL is appropriate to correct high postkeratoplasty astigmatism in eyes operated on for cataract.
No author has a financial or proprietary interest in any material or method mentioned.
Host and graft thickness after descemet stripping endothelial keratoplasty for fuchs endothelial dystrophy
2010, American Journal of Ophthalmology
Citation Excerpt :
Similarly, in a retrospective series, Di Pascuale and associates found that total central corneal thickness and central graft thickness stabilized by 3 to 6 months after DSEK,15 and a study by Pogorelov and associates also suggested stabilization of total central corneal thickness and graft thickness by 8 weeks after DSEK.16 These results are similar to those after penetrating keratoplasty, where corneal (graft) thickness stabilizes by 2 to 3 months.17,18 After DSEK, thicker corneas and grafts were not associated with higher forward light scatter that could degrade the retinal image.
To determine relationships between vision, forward scatter, and total corneal and graft thicknesses after Descemet stripping endothelial keratoplasty (DSEK).
Prospective, cohort study.
Forty-four eyes with Fuchs endothelial dystrophy were examined before and at 1, 3, 6, and 12 months after DSEK; all eyes were pseudophakic after surgery. Central total corneal and graft thicknesses were measured using confocal microscopy. Best-corrected high-contrast visual acuity (BCVA) was measured using the electronic Early Treatment Diabetic Retinopathy Study protocol, and forward light scatter was measured using a straylight meter.
Total corneal thickness was 610 ± 50 μm (mean ± standard deviation) before DSEK, increased to 680 ± 74 μm by 1 month after DSEK (P < .001), and stabilized at 660 ± 68 μm by 3 months after DSEK (P = .03 vs 1 month). Graft thickness was 170 ± 57 μm at 1 month, decreased to 157 ± 49 μm by 3 months (P = .004), and then remained stable through 12 months (156 ± 51 μm; P = .99 vs 3 months). BCVA was 0.44 ± 0.21 logarithm of the minimal angle of resolution (logMAR) units (Snellen equivalent, 20/55) before DSEK, improved to 0.26 ± 0.20 logMAR units (Snellen equivalent, 20/36) by 3 months (P < .001), and improved to 0.16 ± 0.16 logMAR units (Snellen equivalent, 20/29) at 12 months (P < .001 vs 3 months). BCVA and forward light scatter did not correlate with corneal or graft thickness after DSEK.
Stromal edema resolves by 3 months after DSEK for Fuchs dystrophy, whereas visual acuity continues to improve through 12 months. Thicker corneas and grafts are not associated with worse visual acuity or increased forward scatter.

View all citing articles on Scopus

: Manuscript no. 240537.

: Supported by the Paris VI University, Paris, France.

: The authors have no proprietary, commercial, or financial interests in any of the products described in this study.

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Original articleOutcome of Graft Central Thickness After Penetrating Keratoplasty

Objective

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Study Design

Results

Discussion

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Précision et fiabilité de la pachymétrie Orbscan et ultrasonique

J Fr Ophtalmol

Scanning-slit and specular microscopic pachymetry in comparison with ultrasonic determination of corneal thickness

Cornea

A comparison of two pachymetric systems: slit-scanning and ultrasonic

CLAO J

Original article
Outcome of Graft Central Thickness After Penetrating Keratoplasty