Less Invasive Surgery After Failed Penetrating Keratoplasty

By Gabriel Miller

May 02, 2014

NEW YORK (Reuters Health) - For patients who have failed a first cornea transplant with penetrating keratoplasty, a less invasive procedure known as Descemet's stripping automated endothelial keratoplasty (DSAEK) can be used to redo the procedure safely, with comparable visual outcomes, according to a new study.

Still, not all researchers and clinicians agree that DSAEK should be considered the standard treatment for failed penetrating keratoplasty.

"I think it is perhaps premature to say that DSAEK should replace a repeat penetrating keratoplasty as the standard of care if the first penetrating keratoplasty fails," said Dr. Keryn Williams, of Flinders University in Adelaide, Australia, in an email. "The decision on the type of surgery to be performed will likely always be context-dependent."

Dr. Williams has published multiple studies of corneal grafts, though she was not involved in the new research.

Dr. David C. Ritterband, the assistant director of cornea and refractive surgery at The New York Eye and Ear Infirmary in New York City, who also was not involved in the study, told Reuters Health the procedure "shouldn't be the standard, it should be case-by-case."

Those with more severe astigmatism following their first penetrating keratoplasty may not be candidates for DSAEK, he said.

However, the study's lead author, Dr. Danny Mitry, an ophthalmic surgeon at Moorfields Eye Hospital in London, England, said that in general the less invasive DSAEK procedure is a better approach.

"Advantages over penetrating keratoplasty are as for keyhole surgery generally - the operation is easier to perform under local anesthetic and has a faster recovery," Dr. Mitry said. "Longer term results are as good as penetrating keratoplasty."

Unlike penetrating keratoplasty, which removes a thicker section of the cornea, DSAEK removes only Descemet's membrane and replaces it with donor tissue through a much smaller incision.

The study, published online April 24 in JAMA Ophthalmology, assessed graft and visual outcomes in a series of 246 patients that underwent DSAEK after failed penetrating keratoplasty at six tertiary referral surgical centers in the US, Europe, and Asia. Eighteen percent of patients had failed more than one penetrating keratoplasty prior to undergoing DSAEK.

The authors acknowledged that patients were picked selectively because they were good candidates for a DSAEK approach.

Median follow-up was 17 months. A total of 19.1% of DSAEK grafts failed. The cumulative probability of graft survival was 0.89 at one year, 0.74 at three years, and 0.47 at five years. Median time to graft rejection was 13 months.

The main factors associated with failure after DSAEK were younger age, previous tube filtration surgery, and a rejection episode prior to the initial penetrating keratoplasty failure.

Operations were more successful at smaller centers with only a single surgeon, which Dr. Mitry said likely had to do with a higher volume of surgeries and simpler cases at these centers.

SOURCE: http://bit.ly/1fSGhrL

JAMA Ophthalmol 2014.

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