Elsevier

Ophthalmology

Volume 108, Issue 3, March 2001, Pages 461-469
Ophthalmology

The profile of repeated corneal transplantation

https://doi.org/10.1016/S0161-6420(00)00544-3Get rights and content

Abstract

Purpose

To evaluate the primary indications for corneal transplantation in patients with repeated keratoplasties, graft survival, the causes and risk factors for failure.

Setting

Tertiary referral care center.

Design

Retrospective, noncomparative case series.

Methods

Charts of all patients who underwent repeated corneal transplantation between 1985 and 1998 were reviewed. Eighty patients underwent repeated corneal transplantation, of which six underwent repeated corneal transplantation in both eyes, totaling 86 eyes. A total of 208 keratoplasties were performed in this group; 86 primary and 122 repeated keratoplasties. The most common primary indications for corneal transplantation were vascularized corneal scar in 31 of the 86 eyes (36%), followed by pseudophakic and aphakic bullous keratopathy (PBK, ABK). Of the repeated transplants, 55 eyes (64%) had one repeated graft, 27 eyes (31.4%) had two repeated grafts, three (3.5%) had three repeated grafts, and one (1.2%) had four repeated transplants.

Main outcome measures

Final visual outcome and clarity of corneal graft.

Results

At the end of the follow-up period, 44 of the 86 eyes (51%) had clear grafts, but only 39.5% had good visual outcome. The mean survival periods of the repeated transplants decreased gradually with the number of regrafting procedures, from 14.3 to 8.7 months. The mean survival period was longer for patients with ABK, PBK, and secondary glaucoma, and shorter for patients who experienced graft ulcer or surface disorders. Graft failure was unrelated to graft size, but was associated with vascularization (P = 0.025), additional surgical procedures (P < 0.0001), and postoperative complications (P < 0.0001). There was a constant tendency for decrease in visual acuity with time. Final visual acuity was 20/20 to 20/40 in 13 of the 86 eyes (15%), 20/80 to 20/200 in 23 eyes (27%), and less than 20/200 in 50 eyes (58%). The most common complication was immune rejection, which occurred in 65 of the 208 transplants (31%), followed by secondary glaucoma in 48 eyes (23%) and cataract in 19 eyes (9%). Graft survival decreased remarkably after the third and forth regrafts, to 25% and 0%, respectively, compared with the first and second regrafts, 37% and 43%, respectively.

Conclusions

“High-risk” preoperative conditions, postoperative complications, and the need for additional surgical interventions may decrease graft survival. Close follow-up, extended use of antiinflammatory, antiviral, and immunosuppressive drugs, and avoiding additional surgical interventions as much as possible may decrease graft failure and the need for repeated keratoplasties.

Section snippets

Participants and methods

Eighty patients underwent repeated corneal transplantations at our institute between 1985 and 1998, and all were included in this study. Forty-one of the patients were female and 39 were male. The patients’ age at the primary transplantation ranged between 4 and 83 years (mean, 51.7 years). Follow-up period extended for at least 6 months after the last transplantation. The average follow-up period from the time of primary transplantation until the end of the follow-up period was 89.5 months.

Graft survival

At the end of the follow-up period, 44 of the 86 eyes (51%) had clear grafts, but 10 of them (11.6%) had poor visual outcome because of posterior segment abnormalities. The mean survival period of the primary graft was 14.3 months, the first regraft survived for a mean of 12.3 months, the second regraft survived for a mean of 11.4 months, the third regraft survived for a mean of 8.7 months, and the single fourth regraft survived for 20 months (Fig 2). The survival analysis, as plotted in the

Discussion

Our data indicate that the mean corneal graft survival time decreases with subsequent grafting. The survival time may be predicted for different causes of failure, being very short for primary endothelial dysfunction and the longest for postoperative glaucoma. Postoperative complications and additional intra- and postoperative surgical interventions were associated with decreased survival of the repeated grafts.

The primary indications for repeated corneal transplantation differed from those for

Acknowledgements

The authors thank Orly Yakir, MA, for statistical assistance.

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