Damian McNamara

April 08, 2013

BOSTON, Massachusetts — Although immediate intervention might seem intuitive for newborns requiring corneal transplantation, waiting a few months is a viable option, a new study suggests.

Investigators found no statistically significant difference in graft survival or visual outcome after penetrating keratoplasty in infants younger than 3 months of age and in those older than 3 months.

"It may be okay to wait a few months to make penetrating keratoplasty technically easier to perform," Raymond G. Areaux Jr., MD, from the Children's Hospital of Philadelphia in Pennsylvania, told Medscape Medical News.

After promising results from a pilot study of 14 infants who underwent early penetrating keratoplasty, Dr. Areaux and his colleagues evaluated another 53 children. The primary goal of their multicenter retrospective cohort study was to determine the impact of age on corneal transplant graft survival and visual acuity.

Dr. Areaux presented the results here at the American Association for Pediatric Ophthalmology and Strabismus 39th Annual Meeting.

Of the 67 children who underwent corneal transplantation, 25 eyes were in children younger than 3 months of age (early surgery) and 54 were in children older than 3 months (late surgery).

Over a mean follow-up of 19.5 months, the difference in graft survival between groups "was clearly not statistically significant," said Dr. Areaux. The same was true for time to graft failure.

Table. Outcomes After Corneal Transplantation in Young Infants

Outcomes Early Surgery (n = 25 eyes) Late Surgery (n = 54 eyes) P value
Graft survival 64.0% 64.5% 1.00
Good or excellent visual outcome 36.0% 57.0% .19


"It appears that graft failure rates are the same, regardless of what point in the first year of life you perform a corneal transplant," Dr. Areaux said. "In the first few months of life, penetrating keratoplasty is complicated intraoperatively by a softer scleral shell and a smaller eye with more positive pressure. Also, we all know the infant eye grows very rapidly; even a few weeks of growth can dramatically help to simplify your surgery."

Kaplan–Meier analysis for graft survival revealed "2 lines parallel between early and late; again not statistically significant different." About 80% of grafts had survived at 1.1 years (95% confidence interval [CI], 0.69 - 0.88) and 47% had survived at 5.8 years (95% CI, 0.30 - 0.61).

"We can also say that early penetrating keratoplasty...did not seem to improve visual outcome, which stands in marked contradistinction to what we all experience with congenital cataract surgery," Dr. Areaux said.

The vast majority of eyes — 76 of 79 — underwent transplantation to correct congenital corneal opacities. Graft failure was defined as opacification plus or minus ectasia, perforation, or repeat transplantation. The researchers rated vision as poor, fair, good, or excellent.

The study was not randomized, which is a potential limitation. In addition, the researchers did not control for baseline neurologic abnormalities, the degree of congenital corneal opacity, or the intensity of visual rehabilitation.

During a panel discussion, Kamiar Mireskandari, MD, noted that the level of corneal opacity "makes a huge difference. It could be that your transplants before 90 days were your more severe cases." He added that "the later ones may have been managed more for amblyopia before they went on to have the transplant." Dr. Mireskandari is a staff ophthalmologist at the Hospital for Sick Children and assistant professor of ophthalmology and vision sciences at the University of Toronto in Ontario, Canada.

"That's a valid point," Dr. Areaux acknowledged. "We stated outright that that's a limitation of the study; it was not controlled. It was also a retrospective review."

Dr. Areaux and Dr. Mireskandari have disclosed no relevant financial relationships.

American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 39th Annual Meeting: Abstract 6. Presented April 4, 2013.