Real-World Keratoplasty Outcomes

Christopher J. Rapuano, MD


August 19, 2014

A Comparison of Lamellar and Penetrating Keratoplasty Outcomes: A Registry Study

Coster DJ, Lowe MT, Keane MC, Williams KA; Australian Corneal Graft Registry Contributors
Ophthalmology. 2014;121:979-987

Study Summary

The Australian Graft Registry was started in 1985 to track corneal transplant outcomes throughout the country. This study evaluated the results of all corneal transplants performed between January 1996 and February 2013 and reported to the registry. The main outcome measure was graft survival, but visual acuity at last follow-up was also analyzed. Surgeon experience and success of endothelial keratoplasty (EK) were also assessed.

For the 11 years from 1996 through 2006, the number of all types of corneal transplants in the registry was fairly stable, but it increased steadily from 2006 to 2012. The number of deep anterior lamellar keratoplasties (DALKs) and EKs gradually increased, whereas the number of penetrating keratoplasties (PKs) declined from 2006 to 2012. DALKs were primarily done for keratoconus. Graft survival for DALKs performed for keratoconus was statistically significantly worse than these performed for PKs (P < .001). Most EKs were performed for Fuchs dystrophy and pseudophakic bullous keratopathy (PBK). Survival of EKs for these 2 indications was statistically significantly worse than for PKs (P < .001 for both, but worse for Fuchs dystrophy than for PBK). A certain number of EKs and PKs failed within the first month, presumably as a consequence of surgical trauma to the graft. When these failures were removed from the analysis, EK graft survival for Fuchs dystrophy (but not PBK) was still statistically significantly worse than for PK.

Visual acuity at most recent follow-up was worse for both DALK and EK than for PK and also worse for EK. Irreversible graft rejection was responsible for 30% of PK failures, 2% of DALK failures, and 12% of EK failures. Surgeons who performed 100 or more EKs had better outcomes than those who performed fewer EKs, and that difference was observed at the threshold of 20 EKs. Having said that, the authors also looked at EK failures for surgeons who performed at least 50 EKs and found no difference in the rate of failures, comparing earlier cases with later cases for these experienced surgeons.

The study authors concluded that the "real-world" outcomes as demonstrated by this graft registry indicate that PK has superior graft survival and visual acuity outcomes vs early results of DALK and EK.


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