Original Paper Received: August 7, 2013 Accepted after revision: May 28, 2014 Published online: December 13, 2014
Ophthalmic Res 2015;53:36–47 DOI: 10.1159/000365252
Anterior Segment Analysis and Intraocular Pressure Elevation after Penetrating Keratoplasty and Posterior Lamellar Endothelial Keratoplasty Anna-Karina B. Maier a Enken Gundlach a Johannes Gonnermann a Matthias K.J. Klamann a Christian Eulufi a Antonia M. Joussen a Eckart Bertelmann a Peter Rieck b Necip Torun a
a Department of Ophthalmology, Charité – Universitätsmedizin Berlin, Berlin, and b Eye Clinic am Kapellenberg, Potsdam, Germany
Key Words Intraocular pressure elevation · Post-keratoplasty glaucoma · Peripheral anterior synechiae · Anterior chamber optical coherence tomography
Abstract Background: Peripheral anterior synechiae (PAS) is a common problem after penetrating keratoplasty (PK) and leads to intraocular pressure (IOP) elevation. This study examines the risk factors for IOP elevation and post-keratoplasty glaucoma. Methods: A retrospective analysis was performed of 47 eyes following PK and of 65 eyes following Descemet’s stripping endothelial keratoplasty (DSEK) between 2009 and 2011. The assessment included preoperative history of corneal disease and glaucoma, response to treatment, IOP, and visual acuity. Irido-trabecular contacts (ITC), the angle opening distance (AOD 500) and the anterior chamber angle (ACA 500) were calculated. Results: The incidences of IOP elevation and post-keratoplasty glaucoma were 27–36% and 10– 29%, respectively. The incidence did not differ significantly between both procedures. Pre-existing glaucoma increased the risk for developing IOP elevation and post-DSEK glaucoma. Eyes with bullous keratopathy (BK) developed significantly more IOP elevation (p = 0.01, d.f. = 1, χ2 = 6.11) and
© 2014 S. Karger AG, Basel 0030–3747/14/0531–0036$39.50/0 E-Mail [email protected] www.karger.com/ore
post-keratoplasty glaucoma (p = 0.01, d.f. = 1, χ2 = 6.22) than eyes with Fuchs’ endothelial dystrophy. Eyes with ITC developed post-keratoplasty glaucoma significantly more often than eyes without ITC (p = 0.01, d.f. = 1, χ2 = 6.63). Conclusion: IOP elevation and post-keratoplasty glaucoma showed a high incidence. Risk factors like pre-existing glaucoma, BK and PAS elevated the rate of IOP elevation and post-keratoplasty glaucoma for both procedures. © 2014 S. Karger AG, Basel
Introduction
Intraocular pressure (IOP) elevation and glaucoma following keratoplasty have a high incidence and prevalence. Durable uncontrolled elevation of IOP and manifest postkeratoplasty glaucoma are major risk factors for poor visual outcome, endothelial cell loss and subsequent graft failure after keratoplasty. After penetrating keratoplasty (PK), an increasing incidence of IOP elevation from 29 to 80% was reported [1–7]. Post-PK glaucoma occurred in
Anna-Karina B. Maier and Enken Gundlach contributed equally to this work.
Anna-Karina B. Maier, MD Department of Ophthalmology, Campus Virchow Klinikum Charité – Universitätsmedizin Berlin Augustenburger Platz 1, DE–13353 Berlin (Germany) E-Mail anna-karina.maier @ charite.de
Downloaded by: University of Tokyo 157.82.153.40 - 5/18/2015 9:25:34 PM
Materials and Methods Patients A total of 77 PK and 124 DSEK (single or combined procedures) were performed in cases of Fuchs’ endothelial dystrophy (FED) or bullous keratopathy (BK) between January 2009 and December 2011. Data of 47 eyes following PK and of 65 eyes following DSEK were included in this retrospective study. All PK and DSEK were performed at the Department of Ophthalmology, Charité – Universitätsmedizin Berlin, Campus Virchow Klinikum, by four experienced surgeons (P.R., N.T., E.B., and A.J.). For this study, only cases with at least 4 months of follow-up and the last follow-up visit with OCT measurements of the anterior chamber were included. This retrospective study follows the ethical standards of the Declaration of Helsinki.
Anterior Segment Analysis and IOP Elevation after PK and DSEK
Definition of IOP Elevation and Pre-Existing Glaucoma Postoperative IOP elevation was defined as IOP ≥22 mm Hg or an increase in IOP from preoperative value ≥10 mm Hg at any postoperative examination. Single IOP measurements that met these criteria were classified as postoperative IOP elevation. All eyes with postoperative elevated IOP were categorized as described by Maier et al. [13]. All eyes with postoperative elevated IOP were investigated further if they fit the following criteria of steroid-induced glaucoma, post-keratoplasty glaucoma and/or postoperative pupillary block IOP elevation: – Postoperative pupillary block IOP elevation was defined as IOP elevation in the first 2 days after DSEK/keratoplasty. – Eyes in which the IOP normalized (≤21 mm Hg) with steroid therapy ending were defined as steroid-induced glaucoma. – Post-keratoplasty glaucoma, iatrogenic-induced secondary glaucoma, was defined as a durable elevated IOP ≥22 mm Hg at different time points that resulted in the introduction of anti-glaucoma medication or surgical intervention [14, 16, 17]. In patients with pre-existing glaucoma, worsening of the IOP control requiring additional medication or surgery was necessary for the diagnosis of post-keratoplasty glaucoma [14, 16]. The definition was independent of associated visual field loss and optic nerve head changes. Pre-existing glaucoma was defined as including any of the following: a documented history of glaucoma, previous glaucoma surgery, preoperative use of antiglaucomatous medications, glaucomatous excavation of the optic disc, or a cup/disc ratio of ≥0.6. For cases with a suboptimal view of the fundus at preoperative evaluation, the available fundus examination or cup/disc ratio on the subsequent examination was used. Pre- and Postoperative Evaluation Postoperative examinations were performed at 2 weeks, 4–6 weeks and 3, 6, 12, and 24 months after DSEK or PK, including visual acuity, slit-lamp examination, applanation tonometry, and funduscopy. Additionally, at the last follow-up visit an endothelial cell count and OCT measurements of the anterior chamber were performed, as described below. Distant visual acuity was tested with a Snellen chart and expressed as a Snellen decimal number. The Snellen decimal number was converted to logMAR by a visual acuity conversion table [27]. Pre- and postoperative visual acuity at each visit were analysed as best visual acuity with or without refraction or pinhole visual acuity. IOP measurement was performed as a single measurement by Goldmann applanation tonometer (Haag-Streit, Bern, Switzerland). Corneal thickness was not taken into account [28]. In addition, in some cases (
Ophthalmic Res 2015;53:36–47 DOI: 10.1159/000365252
Anterior Segment Analysis and Intraocular Pressure Elevation after Penetrating Keratoplasty and Posterior Lamellar Endothelial Keratoplasty Anna-Karina B. Maier a Enken Gundlach a Johannes Gonnermann a Matthias K.J. Klamann a Christian Eulufi a Antonia M. Joussen a Eckart Bertelmann a Peter Rieck b Necip Torun a
a Department of Ophthalmology, Charité – Universitätsmedizin Berlin, Berlin, and b Eye Clinic am Kapellenberg, Potsdam, Germany
Key Words Intraocular pressure elevation · Post-keratoplasty glaucoma · Peripheral anterior synechiae · Anterior chamber optical coherence tomography
Abstract Background: Peripheral anterior synechiae (PAS) is a common problem after penetrating keratoplasty (PK) and leads to intraocular pressure (IOP) elevation. This study examines the risk factors for IOP elevation and post-keratoplasty glaucoma. Methods: A retrospective analysis was performed of 47 eyes following PK and of 65 eyes following Descemet’s stripping endothelial keratoplasty (DSEK) between 2009 and 2011. The assessment included preoperative history of corneal disease and glaucoma, response to treatment, IOP, and visual acuity. Irido-trabecular contacts (ITC), the angle opening distance (AOD 500) and the anterior chamber angle (ACA 500) were calculated. Results: The incidences of IOP elevation and post-keratoplasty glaucoma were 27–36% and 10– 29%, respectively. The incidence did not differ significantly between both procedures. Pre-existing glaucoma increased the risk for developing IOP elevation and post-DSEK glaucoma. Eyes with bullous keratopathy (BK) developed significantly more IOP elevation (p = 0.01, d.f. = 1, χ2 = 6.11) and
© 2014 S. Karger AG, Basel 0030–3747/14/0531–0036$39.50/0 E-Mail [email protected] www.karger.com/ore
post-keratoplasty glaucoma (p = 0.01, d.f. = 1, χ2 = 6.22) than eyes with Fuchs’ endothelial dystrophy. Eyes with ITC developed post-keratoplasty glaucoma significantly more often than eyes without ITC (p = 0.01, d.f. = 1, χ2 = 6.63). Conclusion: IOP elevation and post-keratoplasty glaucoma showed a high incidence. Risk factors like pre-existing glaucoma, BK and PAS elevated the rate of IOP elevation and post-keratoplasty glaucoma for both procedures. © 2014 S. Karger AG, Basel
Introduction
Intraocular pressure (IOP) elevation and glaucoma following keratoplasty have a high incidence and prevalence. Durable uncontrolled elevation of IOP and manifest postkeratoplasty glaucoma are major risk factors for poor visual outcome, endothelial cell loss and subsequent graft failure after keratoplasty. After penetrating keratoplasty (PK), an increasing incidence of IOP elevation from 29 to 80% was reported [1–7]. Post-PK glaucoma occurred in
Anna-Karina B. Maier and Enken Gundlach contributed equally to this work.
Anna-Karina B. Maier, MD Department of Ophthalmology, Campus Virchow Klinikum Charité – Universitätsmedizin Berlin Augustenburger Platz 1, DE–13353 Berlin (Germany) E-Mail anna-karina.maier @ charite.de
Downloaded by: University of Tokyo 157.82.153.40 - 5/18/2015 9:25:34 PM
Materials and Methods Patients A total of 77 PK and 124 DSEK (single or combined procedures) were performed in cases of Fuchs’ endothelial dystrophy (FED) or bullous keratopathy (BK) between January 2009 and December 2011. Data of 47 eyes following PK and of 65 eyes following DSEK were included in this retrospective study. All PK and DSEK were performed at the Department of Ophthalmology, Charité – Universitätsmedizin Berlin, Campus Virchow Klinikum, by four experienced surgeons (P.R., N.T., E.B., and A.J.). For this study, only cases with at least 4 months of follow-up and the last follow-up visit with OCT measurements of the anterior chamber were included. This retrospective study follows the ethical standards of the Declaration of Helsinki.
Anterior Segment Analysis and IOP Elevation after PK and DSEK
Definition of IOP Elevation and Pre-Existing Glaucoma Postoperative IOP elevation was defined as IOP ≥22 mm Hg or an increase in IOP from preoperative value ≥10 mm Hg at any postoperative examination. Single IOP measurements that met these criteria were classified as postoperative IOP elevation. All eyes with postoperative elevated IOP were categorized as described by Maier et al. [13]. All eyes with postoperative elevated IOP were investigated further if they fit the following criteria of steroid-induced glaucoma, post-keratoplasty glaucoma and/or postoperative pupillary block IOP elevation: – Postoperative pupillary block IOP elevation was defined as IOP elevation in the first 2 days after DSEK/keratoplasty. – Eyes in which the IOP normalized (≤21 mm Hg) with steroid therapy ending were defined as steroid-induced glaucoma. – Post-keratoplasty glaucoma, iatrogenic-induced secondary glaucoma, was defined as a durable elevated IOP ≥22 mm Hg at different time points that resulted in the introduction of anti-glaucoma medication or surgical intervention [14, 16, 17]. In patients with pre-existing glaucoma, worsening of the IOP control requiring additional medication or surgery was necessary for the diagnosis of post-keratoplasty glaucoma [14, 16]. The definition was independent of associated visual field loss and optic nerve head changes. Pre-existing glaucoma was defined as including any of the following: a documented history of glaucoma, previous glaucoma surgery, preoperative use of antiglaucomatous medications, glaucomatous excavation of the optic disc, or a cup/disc ratio of ≥0.6. For cases with a suboptimal view of the fundus at preoperative evaluation, the available fundus examination or cup/disc ratio on the subsequent examination was used. Pre- and Postoperative Evaluation Postoperative examinations were performed at 2 weeks, 4–6 weeks and 3, 6, 12, and 24 months after DSEK or PK, including visual acuity, slit-lamp examination, applanation tonometry, and funduscopy. Additionally, at the last follow-up visit an endothelial cell count and OCT measurements of the anterior chamber were performed, as described below. Distant visual acuity was tested with a Snellen chart and expressed as a Snellen decimal number. The Snellen decimal number was converted to logMAR by a visual acuity conversion table [27]. Pre- and postoperative visual acuity at each visit were analysed as best visual acuity with or without refraction or pinhole visual acuity. IOP measurement was performed as a single measurement by Goldmann applanation tonometer (Haag-Streit, Bern, Switzerland). Corneal thickness was not taken into account [28]. In addition, in some cases (
