1. 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

2. 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

3. 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

4. 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, )
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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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:
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: