Keratoplasty in tenth decade

Good results can be achieved with corneal grafts in patients in their 90s. Roibeard Ó hÉineacháin reports

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Special considerations must be taken into account when performing keratoplasty procedures in very elderly patients, but in the great majority of cases there is good graft survival and good visual outcomes, according to a study presented by Harry Levine at the 25th ESCRS Winter Meeting. “In our experience, corneal transplantation can be considered a safe and successful procedure in improving visual acuity for patients over 90 years of age with the proper preoperative screening. A multi-disciplinary approach involving ophthalmologists, anaesthesiologists and primary care providers is of key importance to achieve good outcomes in this challenging population,” said Levine an MD/MPH candidate at the Miller School of Medicine, University of Miami, Miami, Florida, US. Levine, along with Guillermo Amescua MD, an associate professor of Clinical Ophthalmology and Medical Director of the Ocular Surface Program at the Bascom Palmer Eye Institute, Miami, FL, US, and their colleagues reviewed the charts of 58 eyes of 52 consecutive patients selected from a specimen database from the Florida Lions Eye Bank. All patients were at least 90 years old at the time of surgery, with a mean age of 93.2 years, and all had at least three months of follow-up, he noted. The patients’ indications for surgery were pseudophakic bullous keratopathy in 29%, Fuchs’ endothelial dystrophy in 21%, perforated corneal ulcer in 19%, glaucoma-associated corneal decompensation in 27.6% and band keratopathy in 1.7%. Their ocular comorbidities included glaucoma in 62%, age-related macular degeneration in 24% and prior corneal transplant in 36%. Their systemic comorbidities were hypertension in 81%, hyperlipidaemia in 40.4% and arthritis in 61.5%. The surgeries performed were penetrating keratoplasty (PKP) in 43%, Descemet’s stripping automated endothelial keratoplasty (DSAEK) in 48%, keratoprosthesis in 7% and a patch graft in 1.7%. Concomitant interventions were needed in 60% of cases. All cases were performed under monitored anaesthesia care with peribulbar block and sedation with midazolam and fentanyl or remifentanil. Levine noted that patients’ mean best-corrected visual acuity (BCVA) improved by -0.3 LogMAR (p<0.01) at one postoperative month and by 0.4 LogMAR (p<0.01) at 12 postoperative months. There were no significant differences between the transplant types in terms of their achieved BCVAs. Overall graft survival was 88% at 12 months and 66% at 24 months. Among eyes that underwent PKP, graft survival was 85% at 12 months and 47% at 24 months. Among DSAEKtreated eyes, graft survival was 94% throughout 48 months of follow-up. In the eyes receiving a keratoprosthesis, the implant remained intact throughout 48 months of follow-up. Complications, apart from graft failure or rejection, included intraoperative choroidal haemorrhage in an eye undergoing PKP, pupillary block in a DSAEK-treated eye and retrolenticular membrane in an eye with keratoprosthesis. There were no major complications related to anaesthesia. Harry Levine: h.levine1@med.miami.edu