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Price Vision Price Vision GroupGroup&&

Cornea ResearchCornea ResearchFoundation ofFoundation of

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Descemet -Descemet -Stripping Stripping

Endothelial Endothelial Keratoplasty :Keratoplasty :

Survival Survival Outcomes in Outcomes in

Eyes with Pre-Eyes with Pre-existing existing

GlaucomaGlaucoma

Descemet-Stripping Endothelial Keratoplasty: Descemet-Stripping Endothelial Keratoplasty: Survival Outcomes in Eyes with Pre-existing Survival Outcomes in Eyes with Pre-existing

GlaucomaGlaucoma

Arundhati Anshu,MD;Marianne O. Price, PhD; Francis W. Price, MD.

*Dr. Francis W. Price receives travel grants from Moria.

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IntroductionIntroductionThere is complex interaction between factors influencing outcomes of

corneal transplants and glaucoma management. Glaucoma is recognized as a risk

factor for penetrating keratoplasty failure, and conversely, grafts are a risk factor

for both the development and deterioration of glaucoma. The Australian Corneal

Graft registry and several other large series have reported that glaucoma and/or

glaucoma surgery is associated with increased risk of graft failure in full thickness

corneal transplants.

Descemet stripping endothelial automated

keratoplasty (DSAEK), has been widely adopted for the

treatment of endothelial disorders. DSAEK in eyes with

trabeculectomy and shunt devices can be technically

challenging and requires technique modifications to

achieve good outcomes. While the long-term survival of PKs

in these high-risk eyes is less than favorable, the same is

not known for DSAEK.



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GlaucomaGlaucoma

ee--PosterPoster To evaluate long-term survival outcomes of DSAEK

in eyes with pre-existing glaucoma.



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GlaucomaGlaucoma

PurposePurpose

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Endothelial Endothelial Keratoplasty: Keratoplasty:



GlaucomaGlaucoma

• A retrospective interventional case series

Parameters Evaluated

• Presence or absence of pre-existing glaucoma• Type of glaucoma surgery• Graft survival in eyes with and without glaucoma• Graft survival in eyes with glaucoma surgery

Inclusion and Exclusion Criteria:

• Patients undergoing their first DSAEK for endothelial dysfunction.

• Regrafts and eyes that developed glaucoma or underwent glaucoma surgery after DSAEK were excluded from the survival analysis

Materials and MethodsMaterials and Methods

• The cumulative probability of graft survival was calculated using Kaplan-Meier

survival analysis and log rank test.

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GlaucomaGlaucoma

Results Results

• N = 350 consecutive eyes• Mean age: 69 years (S.D – 12; Range – 22-94 years)• Female:Male::241:109• Pre-operative diagnosis: Fuchs endothelial dystrophy (314,

90%) and corneal edema from other causes (36, 10%)• Eyes with pre-existing glaucoma: 45 (12.5%)• Eyes with prior glaucoma surgery: 13 (Trabeculectomy – 5;

Shunt procedure – 8)

DemographicsDemographics

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ResultsResults



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GlaucomaGlaucoma

•Overall, 12/335 eyes without prior glaucoma surgery failed (3.5%)

•2 of 5 eyes with a prior trabeculectomy failed (40%)

•5 of 8 eyes with a prior shunt procedure failed (63%)

Graft failure ratesGraft failure rates

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ResultsResults



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GlaucomaGlaucoma

•Kaplan-Meier survival analysis showed that the overall graft survival at 1, 2, 3, 4 and 5 years was 98%, 97%, 95%, 94%, and 93% respectively.

•Graft survival in eyes with medically managed glaucoma was 100%, 96%, 96%, 91% and 91% at 1, 2, 3, 4 and 5 years respectively and this was not statistically significant (P=0.48) as seen in Figure 1 below.

Graft survival –medically managed glaucomaGraft survival –medically managed glaucoma

Figure 1

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ResultsResults



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Endothelial Endothelial Keratoplasty : Keratoplasty :



GlaucomaGlaucoma

In eyes with pre-existing shunt surgery, graft survival was 100% at 1 year, 84% at 2 years, 76% at 3 years, 56% at 4 years and 30% at 5 years and this was statistically significant when compared to eyes without prior shunt surgery (p<0.0001) as depicted in Figure 2.

Graft survival – eyes with shunt surgeryGraft survival – eyes with shunt surgery

Figure 2

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Discussion and conclusionDiscussion and conclusion



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GlaucomaGlaucoma

In eyes undergoing a penetrating keratoplasty (PK), it has been well documented that glaucoma surgery affects graft survival adversely. Glaucoma surgery generally indicates more severe glaucoma and a failure of medical therapy, and issues such as anterior chamber shallowing, and increased inflammation are all prejudicial to graft survival.

Trabeculectomy is accompanied by the use of antimetabolites that are toxic to the corneal endothelium, which, combined with the known decrease in endothelial cell density after intraocular surgery, could predispose to endothelial failure. It has been demonstrated in previous studies that the blood– aqueous barrier is transiently disrupted after trabeculectomy leading to increased immune-modulatory and/or inflammatory molecules in the anterior chamber that could cause graft rejection and failure.

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Discussion and conclusionDiscussion and conclusion



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GlaucomaGlaucoma

Disruption of the blood–aqueous barrier is also produced by tube-shunt devices, and this could lead to an increased rate of rejection and hence graft failure. Drainage tube implants may damage the corneal endothelium by mechanical means or by permitting retrograde entrance of inflammatory cells into the anterior chamber, and increasing the risk of rejection and hence graft failure.

The results of this study show that similar to PK, glaucoma surgery was a significantly negative predictor of graft survival in eyes undergoing DSAEK, with the cumulative 5-year graft survival in eyes with prior glaucoma surgery being 30% compared to 93% in eyes without glaucoma surgery (p<0.0001).

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