Glaucoma Progression after Descemet’s Stripping Endothelial Keratoplasty Neelofar Ghaznawi MD, Melissa B Daluvoy MD, Ajoy Virdi MD, Edwin S Chen, Kristin M Hammersmith MD, Christopher J Rapuano MD The authors have no financial interest in the subject matter of this presentation

Descemet’s Stripping Endothelial Keratoplasty DSEK provides rapid healing, predictable refractive outcomes, and tectonic stability. Evolution of DSEK technique has resulted in better visual outcomes and fewer post-operative complications. DSEK has become the preferred treatment for any endothelial dysfunction. The indications for DSEK have expanded from Fuchs Dystrophy and PBK, failed PK, aphakic bullous keratopathy, aniridia, ICE syndromes and CHED.

Purpose and Design Purpose 51 22 Glaucoma 29 Control 12 Surgical To characterize the pattern of glaucoma progression after Descemet’s stripping endothelial keratoplasty in patients without preexisting glaucoma and in those with preexisting glaucoma with and without prior glaucoma surgery To compare visual outcomes among the 3 groups 51 DSAEK 22 Glaucoma 29 Control 12 Surgical 10 Medical Outcome Measures Visual Acuity IOP Steroid dose IOP lowering medications Rejection Glaucoma procedures Little is known regarding the incidence of glaucoma and its effect on visual outcome after DSAEK. Preexisting glaucoma was defined as any of the following: documented history of glaucoma, preoperative use of anti glaucomatous medications and preoperative IOP >24, of C/D > 0.6. Post operative IOP increase was defined as any initiation or increase in anti glaucomatous medications or IOP > 25 or a relative increase in IOP >10 mmHg above baseline

Summary of Demographics and Baseline Characteristics Demographics/ Baseline Characteristics Controls (29 eyes) Glaucoma (Medical) ( 10 eyes) (Surgical) (12 eyes) p values OD:OS 16:13 7:3 5:7 0.55 % Caucasian 89% 100% 86% 0.07 % Fuchs' Endothelial Dystrophy 77% 30% 29% .0001 Preoperative VA (median [min, max]) 20/100 (20/25, CF) 20/400 (20/50, CF) 20/400 (20/100, CF) .003 Preoperative IOP (mmHg, median [min, max] 13 (8,22) 15 (12,18) 11 (5,17) .013 Cup-to- disc ratio 0.30 (0.2-0.65) 0.49 (0.2-0.6) 0.65 (0.35-0.9) There are some significant differences between the two group. 1)Although differences in preoperative IOP were not statistically significant, important and significant differences were in the indications for DSAEK, preoperative vision and Cup to disc ratio

Results 2 Surgical Medical Control p< .05 p< .05 p< .05 Initiation or Increase in Glaucoma Medications Incidence of IOP Elevation p< .05 p< .05 Use of a Less Potent Steroid 2 Glaucoma Procedures Surgical Medical Control Incidence of post op IOP elevation at any point during study. IOP elevation again defined as IOP greater than or equal to 24 or 10 mmHg above baseline at any point during the follow up period. 21% of patients with out any history of glaucoma experienced at least one episode of elevated IOP. Which was significantly lower than either the medically managed glaucoma group and those with prior glaucoma surgeries. p< .05

Percentage of Control Eyes With Elevated IOP Over the course of the of follow up, the percentage of eyes without elevated IOP remained consistently above 84 % with the peak incidence of glaucoma occurring at 4-5 months post operatively

Final Visual Outcomes in Subgroups VA Median (min, max) Without Preexisting Glaucoma N=29 With Preexisting N=10 With Prior Glaucoma Surgeries N=12 P Value Preoperative 20/100 (20/25, CF) 20/400 (20/50, CF) 20/400 (20/100, CF) 0.003 1 year 20/40 (20/25, 20/400) 20/50 (20/40, 20/70) 20/60 (20/25, 20/400) 0.112 Median lines of improvement 5.3 5.5 5.2 0.979 1 year compared to baseline P< 0.0001 All 3 groups gained statistically significant improvement in vision at 12 months compared with baseline. Compared with controls the patients with pre existing glaucoma had poorer median VA at baseline but showed comparable vision at 12 months. Furthermore, all groups gained about 5 lines of vision, the differences between the groups were not statistically significant.

Conclusions Incidence of elevated IOP after DSEK: Without preexisting glaucoma: 21% With glaucoma and no h/o surgery: 50% With glaucoma and prior surgery: 42% At 1 year follow up glaucoma medication added in: 5 % of patients without glaucoma 50 % of patients with medically managed glaucoma 13% of patients with prior glaucoma surgery At 1 year 17% of patients with prior surgery required an additional glaucoma drainage procedure. All groups gained statistically significant improvement in VA at 12 months compared with baseline

Conclusions Given high incidence of post operative IOP elevation, close monitoring of IOP is warranted. Preexisting glaucoma does not negatively affect improvement of VA after DSEK.

References Chien AM, Schmidt CM, Cohen EJ. Glaucoma in the immediate postoperative period after penetrating keratoplasty. Am J Ophthalmol. 1193:115:711-714 Goldber DB, Schanzlin DJ, Brown SI. Incidence of increased intraocular pressure after keratoplasty. Am J Ophthalmol 1981:92:372-7. Williams KA, Roder D, Esterman A, Muehlberg SM, Coster DL. Factors predictive of corneal graft survival; report from the Australian Corneal Graft Registry. Ophthalmology 1992; 99: 403 414 Suh LH, Yoo, SH, Deobhakta A, Donaldson KE, Alfonso EC, Culbertson WW, O’Brien TP. Complication of descemet’s stripping with automated endothelial keratoplasty: Survey of 118 at one institute. Ophthalmology; 2008; 115:1517-1724 Terry MA. Endothelial keratoplasty: A simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block. Ophthalmology. 2008; 115:1179-1186 Terry MA. Histology of dislocations in endothelial keratoplasty (DSEK and DLEK): A laboratory-based, surgical solution to dislocation in 100 consecutive DSEK cases. Cornea. 2006; 25: 926-932 Terry MA. Endothelial keratoplasty: The influence of preoperative donor endothelial cell densities on dislocation, primary graft failure, and 1 year cell counts. Cornea 2008; 27:1131-1137 Vajaranant TS, Price, MO, Price WP. Visual acuity and IOP after DSEK in eyes with and without glaucoma. Ophthalmology; 116:1644-1650 Price MO, Price FW Jr, Trespalacios R. Endothelial keratoplasty of aniridic aphakic eyes. J Cataract Refract Surg 2007; 33:376-379 Wylegala E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg; 2008; 34:1708-1714