Somasheila I. Murthy, Prashant Garg, Pravin K. Vaddavalli ID: 17637 Clinical Outcomes and Risk Factors for Graft Failure After Keratoplasty for Macular Corneal Dystrophy Jagadesh C. Reddy Somasheila I. Murthy, Prashant Garg, Pravin K. Vaddavalli The authors have no financial interests in the subject matter of this presentation

Purpose The aim of this study was to compare visual acuity, clinical outcomes, complications, and risk factors for graft failure after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for macular corneal dystrophy

Methods Study design: Retrospective review of clinical records of 104 patients with MCD who underwent corneal transplantation and followed up for at least 12 months Study location: Cornea service, LV Prasad Eye Institute, India Study duration: April 2001 to June 2009 Study ethics: Approved by the institutional review board and was conducted in strict adherence to the tenets of the Declaration of Helsinki

Results Parameter DALK PK Number of eyes (patients) 21 (20) 109 (84) Mean age (SD, range) years 30 (11.87, 5-50) 34 (11.53, 18-65) Gender, male : female (%) 14:6 (70:30) 48:36 (57:43) Laterality, RE:LE:BE 9:10:1 34:25:25 Mean follow-up (SD, Range) in months 17 (8.80, 12-46 ) 43 (24.13, 12–104) Mean donor size (SD) 8.02 (0.28) mm 8.11 (0.22) mm Mean recipient size (SD) 7.59 (0.24) mm 7.64 (0.23) mm DALK-deep anterior lamellar keratoplasty, PK-penetrating Keratoplasty, RE-right eye, LE-left eye, BE-both eyes, SD-standard deviation, mm-millimeters Table-1, Patient characteristics and surgical data of the two groups

Results Parameter DALK PK P value* Mean pre-operative LogMAR BCVA (SD) 1.09 (0.57) 1.27 (0.61) 0.22 Mean Log MAR BCVA at 3 months (SD) 0.58 (0.39) 0.45 (0.51) 0.52 Mean Log MAR BCVA at 12 months (SD) 0.43 (0.39) 0.89 Mean Log MAR BCVA at final follow-up (SD) 0.45 (0.59) 0.56 (0.67) 0.50 Mean Refractive spherical equivalent at 12 months (SD) 1.72 (3.08) D 0.34 (3.98) D 0.31 Mean Refractive spherical equivalent at final follow-up (SD) 0.72 (2.31) D -0.63 (3.68) D 0.29 Mean cylinder (median) at 12 months -3.25 (-3.5) D -3.30 (-3) D 0.75 Mean cylinder (median) at final follow-up -3.31 (-3) D -2.48 (2.62) D 0.33 DALK-deep anterior lamellar keratoplasty, PK-penetrating keratoplasty, Log MAR-logarithm of the minimum angle of resolution equivalents, BCVA- best corrected distance visual acuity, SD- standard deviation, D-diopters *McNemar test was used Table-2 Comparison of visual and refractive results between the two groups

Results Complication DALK PK Intraoperative : Conversion to PK 3 - DM micro perforation 5 Spontaneous expulsion of lens 1 Post-operative Double anterior chamber 9 Wound leak: re-suturing 2 Graft dehiscence: re-suturing PED-tarsorrhaphy Secondary glaucoma 12 Cataract 4 Graft infiltrate Endophthalmitis (at 12 months) Graft rejection episodes-endothelial 27 DALK-deep anterior lamellar keratoplasty,PK-penetrating keratoplasty, DM- descemet membrane, PED-persistant epithelial defect Table-3: Complications noted in both the groups

Results Table-4, Causes of graft failure in the two groups Parameter DALK PK Endothelial rejection 17 Secondary glaucoma 3 Graft infiltrate Endophthalmitis 2 Intra -operative micro perforation- postoperative DM detachment-C3F8 injection once-endothelial decompensation after cataract surgery 1 Poor ocular surface- sterile perforation Postoperative DM detachment (C3F8 injected twice in one case) DALK-deep anterior lamellar keratoplasty, PK-penetrating Keratoplasty, DM-descemet’s membrane, C3F8- perfluropropane Table-4, Causes of graft failure in the two groups

Slit image showing deposits in the deeper layers Slit image showing double anterior chamber Slit image showing DM detachment superiorly Intradescemetic split leading to entrapment of air which was absorbed spontaneously ASOCT showing double AC of the same patient seen above

Kaplan-Meier Survival plot Survival rate of the DALK group was 80% at 12 months and remained 70% at 24, 36, and 48 months. Survival rate of the PK group was 93%, 88%, 83%, 78%, 65%, 65%, and 52% at 12, 24, 36, 48, 72, 84, and 96 months, respectively Kaplan-Meier Survival plot

Literature Review Study/year Indication Eyes Micro perforation Conversi -on to PK Double AC Sogutlu Sari E, et al./20131 MCD 35 10.7 % 14.6 % 2.8% Kawashima M. et al./20062   10 20 % 40% Present study/2014 21 24% 12.5% 43% Reinhart WJ, et al./20103 ALL 1843 (MCD-17) 11.7 % 2.1 % 3.53% PK: penetrating keratoplasty, AC: anterior chamber, MCD: macular corneal dystrophy Table-5, Literature comparing intra and perioperative complication profile after DALK for MCD and other indications.

Conclusions Visual and refractive outcomes are comparable between DALK and PK with varying complication profiles Graft survival was better in the DALK group with time compared with the PK group Surgical risk factors (DM perforation/Double AC) contribute significantly to endothelial decompensation after DALK rather than only the disease process in MCD DALK may be considered as an option in cases of MCD where there is no direct clinical evidence of deposits on DM The main limitations of this retrospective study are the difference in the number of cases, duration of follow up in between the groups and also lack of endothelial cell density

References Sogutlu Sari E, Kubaloglu A, Unal M, et al. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for macular corneal dystrophy: a randomized trial. Am J Ophthalmol. 2013; 156: 267-274. Kawashima M, Kawakita T, Den S et al. Comparison of deep lamellar keratoplasty and penetrating keratoplasty for lattice and macular corneal dystrophies. Am J Ophthalmol. 2006;142 :304-9. Reinhart WJ, Musch DC, Jacobs DS et al. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmology. 2011;118: 209-18.