Purpose
To identify the most common corneal transplant procedures, indications, coexisting ocular diseases, and outcomes in elderly patients, and to compare younger geriatric patients with super-geriatric patients.
Design
Retrospective case series.
Methods
Data of all patients 65 years old and older who underwent corneal transplantation at Wills Eye Institute from April 2007 to January 2013, and were followed up for at least 1 year, were collected. Two hundred seventy-one eyes of 253 patients were divided into 2 groups according to the age of the patient.
Results
Group I (65-79 years old) included 181 eyes and Group II (80 years and older) included 90 eyes. The most common indication was Fuchs endothelial dystrophy, with 78 eyes (43%) in Group I and 34 eyes (38%) in Group II. In Group I, 93 Descemet stripping endothelial keratoplasty (DSEK) (51%), 84 penetrating keratoplasty (PK) (46%), and 4 keratoprosthesis procedures(2%) were performed; in Group II, 37 DSEK (41%), 51 PK (57%), and 2 keratoprosthesis procedures (2%) were performed. Graft survival rate at last visit was 90% for Group I and 88% for Group II. Rejection occurred in 18 Group I eyes (10%) and 7 Group II eyes (8%) ( P = .562).
Conclusion
Endothelial abnormalities were more common indications and keratoconus was a less common indication for surgery in the elderly. Fuchs dystrophy was the leading indication for surgery in both super-geriatric and younger geriatric patients. Graft survival rate was slightly higher in the younger geriatric age group but was not statistically significant. In the elderly, there is an increased prevalence of both glaucoma and retinal diseases that can affect the visual outcomes after corneal transplantation.
Corneal transplantation is a successful procedure that has been performed for decades. The conventional procedure is penetrating keratoplasty (PK), which is a full-thickness transplant of the cornea, but other corneal transplantation techniques are becoming increasingly popular. Interest in endothelial keratoplasty, most commonly Descemet stripping endothelial keratoplasty (DSEK), has grown in recent years because of the significant advantages over PK procedures for eyes with corneal edema. The decision regarding the specific type of procedure for a particular patient depends primarily on the indication and other coexisting ocular diseases.
The geriatric population represents a distinct clinical group in the context of corneal transplantation. Indications for surgery differ compared to younger cohorts and these older patients are more likely to have had previous or coexisting ocular disease or surgery, and the visual prognosis may be significantly worse because of these conditions. A greater likelihood and severity of systemic diseases and use of numerous systemic medications may also influence the follow-up and compliance of geriatric patients. Cooperation and compliance with postoperative medications affect the success of corneal transplantation and may be lower in geriatric patients. Also, age may potentially influence wound healing, immunologic response, and the incidence of intraoperative and postoperative complications. In numerous published series, young recipient age is associated with a higher rate of failure from rejection. The risk of rejection is increased in regrafts and in eyes with several pre-existing conditions such as uveitis, keratitis, anterior iris synechiae, vitreous adhesions, previous anterior segment surgery other than penetrating keratoplasty, and multiple surgeries at the same time. Although glaucoma does not necessarily predispose to rejection, it is an important risk factor for graft failure.
Geriatric patients are a rapidly growing population throughout the world. The United States census of 2010 showed that there were more than 40 million people aged 65 years or older, constituting 13% of the population. As a result, there has been a significant increase in a subgroup of these patients: those older than the age of 80 years, often termed the “super geriatric.” With increasing numbers of those of retirement age, the demand this group places on healthcare systems worldwide will continue to rise. Over the years, there have been many published reports regarding the clinical and demographic aspects of patients who have corneal transplantations, but there are limited data on the geriatric population.
The purpose of this study is to identify, in those patients who are 65 years old and over, the most common corneal transplant procedures and indications, coexisting ocular and systemic diseases, and the visual and tectonic outcomes, and to compare younger geriatric with super-geriatric patients for a 4-year period at Wills Eye Institute.
Methods
After Wills Eye Institute Institutional Review Board approval, the charts of all patients who underwent corneal transplantation in our practice at Wills Eye Institute from April 6, 2007 to January 2, 2013 were identified through a computerized search of our electronic health records system and retrospectively reviewed. Included were all patients who underwent a corneal transplantation at age 65 years and over who had at least 1 year of follow-up. If an eye had more than 1 corneal transplantation at the age of 65 or older, only the first procedure was included in the study. Patients were divided into 2 groups based on the age at the time of corneal procedure; Group I consisted of the patients aged 65-79 years and Group II comprised patients 80 years and over (super-geriatric patients). Patients with less than 1 year of follow-up were excluded from the study.
Data reviewed included the chief complaint before the surgery, ophthalmologic examination at each office visit, indications for the graft, coexisting ocular diseases before the surgery, history of all systemic diseases and prescription medications, complications during surgery, best-corrected visual acuity (BCVA), and graft survival. Visual acuity was measured using a Snellen chart. Visual acuities were divided into 4 groups (≥20/30, 20/40-20/100, 20/200-20/400, and <20/400). The dose and frequency of the steroids administered at last visit were also reviewed. The use of steroid at last visit was categorized and placed into 4 “potency groups” (ie, high, medium, low, and no steroids) according to the dose and strength of the particular steroid ( Table 1 ).
| High | Medium | Low |
|---|---|---|
| Prednisolone acetate/phosphate 1% 4 times a day Prednisolone acetate/phosphate 1% 3 times a day Prednisolone acetate/phosphate 1% 2 times a day Prednisolone acetate/phosphate 1% 1 times a day | Prednisolone acetate 1% 1 time every other day Loteprednol etabonate 0.5% 1 time a day Fluorometholone alcohol 0.25% 1 time a day | Loteprednol etabonate 0.5% 1 time per week or less Fluorometholone alcohol 0.1% 1 time a day or less Prednisolone acetate 0.12% 2 times a day or less Loteprednol etabonate 0.2% 1 time a day or less |
The corneal transplant procedures were DSEK, PK, and keratoprosthesis. Depending on the indication, cataract surgery; intraocular lens placement, removal, or exchange; anterior vitrectomy; or tarsorrhaphy were also performed. All corneal transplants were performed under monitored anesthesia care with lid and retrobulbar block or general anesthesia. Donor corneas were obtained through the Lions Eye Bank of Delaware Valley. The surgical technique for penetrating keratoplasty included use of a Flieringa ring, 0.25-0.50 mm oversize graft, and 10-0 nylon interrupted or combined running/interrupted suture technique. The surgical technique for DSEK included the insertion of 7.5- to 8.5-mm-diameter donor button on a Busin glide (Moria Surgical, Dolyestown, Pennsylvania, USA) or a folding technique using non-coapting forceps through a temporal corneal incision or superior scleral tunnel. For donor tissue, the Moria automated microkeratome (Moria Surgical) was used to remove approximately 300 μm of anterior stroma, leaving a residual bed of stroma. Descemet membrane and endothelium was then trephined. A standard Boston type I keratoprosthesis procedure was performed. Topical and subconjunctival antibiotics and steroid were given at the conclusion of all surgeries.
Postoperatively, initial topical therapy included prednisolone acetate solution 4-6 times a day for at least 1 month, a fourth-generation fluoroquinolone antibiotic 4 times a day for 1 week, and erythromycin or bacitracin ointment at bedtime. The prednisolone acetate solution was then typically slowly tapered to once a day over 4-12 months. Keratoprosthesis patients also received topical fortified vancomycin drops. At each postoperative visit, visual acuity was measured and slit-lamp biomicroscopy performed to assess the condition of the graft. Intraocular pressure was measured by applanation tonometry (Haag Streit, Bern, Switzerland) or Tono-Pen (Reichert Inc, Buffalo, New York, USA) after PK and DSEK and by finger tension after keratoprosthesis.
Graft failure was defined as edema and irreversible loss of clarity. Rejection was defined as the development of a rejection line (epithelial or endothelial), subepithelial infiltrates, stromal keratitis with keratitis precipitates, new keratic precipitates, or a unilateral anterior chamber reaction with spreading corneal edema in a previously thin, clear graft. Any sign of graft rejection was treated promptly with high-dose topical steroids. When failure occurred, observation or retransplantation was performed depending on the clinical situation. All of the recorded findings were reviewed.
Visual acuity was converted to a logMAR scale for the purpose of statistical analysis. In addition to BCVA at specific time points, postoperative BCVA was also included as vision often decreases over time, especially in geriatric patients because of issues unrelated to the graft, and postoperative BCVA may be a more accurate measure of graft outcome. Mann-Whitney U test was used to compare follow-up time between groups. To compare the nominal data, χ 2 tests were used. Graft rejection and failure were compared by Kaplan-Meier estimation and log-rank test. All above tests were performed using Statistical Package for Social Sciences 19.0 (IBM, Endicott, New York, USA). For calculation of sample size, we used Power and Sample Size software, version 3.0.43 (Dupont and Plummer, Vanderbilt University, Nashville, Tennessee, USA). All tests were 2-sided, and P < .05 was considered to be significant.
Results
Patient Data
A total of 303 eyes of 285 patients over the age of 65 years who had undergone a corneal transplant procedure were identified. Because of shorter than 1-year follow-up, 32 eyes were excluded (from 12 men and 20 women, mean age 81.4 years). These patients had undergone 17 PKs, 13 DSEKs, and 2 keratoprosthesis procedures. One other patient was excluded (an 85-year-old woman who underwent a PK) because of incomplete records. Consequently, 271 eyes of 253 patients aged 65 years or older were included in the study. The baseline characteristics included 159 female (63%) and 94 male (37%) patients with an age range at surgery between 65 and 93 years (average 76.61 ± 7.1 years) ( Table 2 ). These 271 eyes were divided into 2 groups according to the age of patient at the time of surgery: 181 grafts (67%) were done when the patient was 65-79 years old (Group I), whereas 90 of the grafts (33%) were done when the patient was 80 years old or older (Group II). Corneal transplantation was performed in both eyes in 18 patients (6.6%). At the time of surgery, 120 patients (47%) had 3 or more systemic diseases and 189 patients (75%) were using 3 or more systemic prescription medicines. All of the operated eyes had at least 1 year follow-up (mean follow-up time: 35.8 ± 14.1 months). The mean follow-up time for Group I was similar to Group II ( P = .111). The chief complaint before surgery was poor vision in 261 eyes (96%); it was pain in only 10 eyes (4%) and was similar in the 2 groups. Indications for surgery in Group I were Fuchs endothelial dystrophy in 78 eyes (43%), pseudophakic bullous keratopathy (PBK) in 40 eyes (22%), and failed previous graft in 28 eyes (15%). Indications for surgery in Group II were Fuchs endothelial dystrophy in 34 eyes (38%), PBK in 31 eyes (34%), and failed previous graft in 21 eyes (23%). Keratoconus was an indication only in 7 eyes (4%), all in Group I ( Table 3 ).
| 65-79 Age Group | ≥80 Age Group | Total | P Value | |
|---|---|---|---|---|
| Number of patients | 165 (65%) | 88 (35%) | 253 | – |
| Sex | ||||
| Female | 105 (64%) | 54 (61%) | 159 (63%) | .722 |
| Male | 60 (36%) | 34 (39%) | 94 (37%) | |
| Age at surgery, y (± SD) | 65-79 (72.33 ± 4.25) | 80-93 (84.63 ± 3.53) | 65-93 (76.61 ± 7.10) | – |
| Bilateral surgery | 16 | 2 | 18 | .029 |
| ≥3 systemic diseases | 74 (45%) | 46 (52%) | 120 (47%) | .497 |
| ≥3 systemic medications | 116 (70%) | 73 (83%) | 189 (75%) | .027 |
| Mean (± SD)follow-up time (mo) | 36.7 ± 13.3 | 34.1 ± 15.6 | 35.8 ± 14.1 | .111 |
| Indications | 65-79 Age Group (181 Eyes) | ≥80 Age Group (90 Eyes) | Total (271 Eyes) | P Value |
|---|---|---|---|---|
| Fuchs endothelial dystrophy | 78 (43%) | 34 (38%) | 112 (41%) | .403 |
| Pseudophakic bullous keratopathy | 40 (22%) | 31 (34%) | 71 (26%) | .030 |
| Failed previous corneal graft | 28 (15%) | 21 (23%) | 49 (18%) | .113 |
| Original diagnosis: | ||||
| Fuchs endothelial dystrophy | 5 | 6 | 11 | .188 |
| Pseudophakic bullous keratopathy | 12 | 6 | 18 | .991 |
| Corneal scar | 5 | 3 | 8 | >.999 |
| Other corneal dystrophies | 2 | 1 | 3 | >.999 |
| Keratoconus | 4 | 1 | 5 | .668 |
| Unknown indication a | 0 | 4 | 4 | .012 |
| Corneal scar | 19 (10%) | 2 (2%) | 21 (8%) | .016 |
| Other corneal dystrophies | 6 (3%) | 2 (2%) | 8 (3%) | >.999 |
| Keratoconus | 7 (4%) | 0 | 7 (3%) | .099 |
| Trauma | 3 (2%) | 0 | 3 (1%) | .553 |
| Total | 181 (100%) | 90 (100%) | 271 (100%) |
a Previous transplantation was in another center and data were not available.
Preoperative coexisting ocular findings were also reviewed. Glaucoma was the chief coexisting ocular finding in all ages. Retinal diseases were more common coexisting ocular findings in Group II than in Group I ( Table 4 ).
| Ocular Findings | 65-79 Age Group (181 Eyes) | ≥80 Age Group (90 Eyes) | Total (271 Eyes) | P Value |
|---|---|---|---|---|
| Glaucoma | 58 (32%) | 43 (48%) | 101 (37%) | .012 |
| Retinal diseases | 17 (9%) | 28 (31%) | 45 (17%) | .000 |
| Cataract | 41 (23%) | 13 (14%) | 54 (20%) | .111 |
| PCIOL | 129 (71%) | 68 (76%) | 197 (73%) | .456 |
| ACIOL | 6 (3%) | 9 (10%) | 15 (6%) | .044 |
| Aphakia | 3 (2%) | 0 | 3 (1%) | .553 |
| Dry eye | 6 (3%) | 9 (10%) | 15 (6%) | .044 |
| Ptosis | 6 (3%) | 3 (3%) | 9 (3%) | >.999 |
| Tarsorrhaphy | 1 (0.5%) | 3 (3%) | 4 (1%) | .108 |
| Blepharitis | 12 (7%) | 6 (7%) | 18 (7%) | .991 |
| Trichiasis | 3 (2%) | 0 | 3 (1%) | .553 |
Surgical Data
A total of 130 DSEK (48%), 135 PK (50%), and 6 keratoprosthesis (2%) surgeries were performed. The most performed procedure in Group I was DSEK and it was 51%; and in Group II was PK and it was 57%. Surgery was combined with cataract extraction in 36 eyes (13%) and with anterior vitrectomy in 26 eyes (10%) ( Table 5 ).
| Corneal Transplants | 65-79 Age Group (181 Eyes) | ≥80 Age Group 0(90 Eyes) | Total (271 Eyes) | P Value |
|---|---|---|---|---|
| DSEK | 93 (51%) | 37 (41%) | 130 (48%) | .111 |
| Only DSEK | 78 (43%) | 34 (38%) | 112 (41%) | .403 |
| DSEK-triple | 14 (8%) | 3 (3%) | 17 (6%) | .159 |
| DSEK-triple/anterior vitrectomy | 1 (0.6%) | 0 | 1 (0.4%) | >.999 |
| PK | 84 (46%) | 51 (57%) | 135 (50%) | .112 |
| Only PK | 52 (29%) | 39 (43%) | 91 (34%) | .017 |
| PK-triple | 15 (8%) | 4 (4%) | 19 (7%) | .243 |
| PK/anteror vitrectomy/IOL exchange | 17 (9%) | 8 (9%) | 25 (9%) | .893 |
| Keratoprosthesis | 4 (2%) | 2 (2%) | 6 (2%) | >.999 |
Complications
In all, 4 DSEK detachments (3% of all DSEKs) and 25 rejections (9% of 130 DSEK and 10% of 135 PK procedures) occurred. Forty-four percent of rejections were after the first year. Eighteen eyes (10%) in Group I and 7 eyes (8%) in Group II had rejection ( P = .562). Overall for these 25 rejected corneas, 14 improved with high-dose topical corticosteroid therapy, whereas 11 progressed to graft failure. In all corneal procedures, graft failure was recorded in 31 eyes (11%) and was managed by either another corneal procedure or observation, depending on the clinical situation and the patient’s desire. Other postoperative complications included 2 eyes with traumatic PK wound dehiscence; both were repaired but 1 eventually required evisceration. Another 2 PK eyes had nontraumatic wound slippage causing severe astigmatism; both underwent wound repair. Another eye after PK had recurrent epithelial defect and stromal melting, and required 2 corneal patch grafts.
Overall graft survival rate was 89% at last follow-up; it was 90% for Group I and 88% for Group II. Graft survival rate at 6 months and at 1, 2, 3, 4, and 5 years was also reviewed. At the end of 1 year follow-up, the number of clear grafts in Group I was 176 (97%) and it was 85 (94%) in Group II. Mean graft survival rate was similar in both groups ( Table 6 ). Kaplan-Meier survival analysis and graft rejection rate are shown in Figures 1 and 2 . The steroid dose in clear grafts at last visit was found to be high in 44 eyes (19%), moderate in 148 eyes (63%), and low in 27 eyes (11%); 17 eyes with clear grafts (7%) were not on steroid therapy at last visit. Steroid potency and dose differences between Group I and Group II and between DSEK and PK groups were not statistically significant ( Table 7 ).
