Glaucoma Progression after Descemet’s Stripping Endothelial Keratoplasty

Glaucoma Progression after Glaucoma Progression after Descemet’s Stripping Endothelial Descemet’s Stripping Endothelial

KeratoplastyKeratoplasty

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 Descemet’s Stripping Endothelial Keratoplasty Keratoplasty

DSEK provides rapid healing, predictable DSEK provides rapid healing, predictable refractive outcomes, and tectonic stability.refractive outcomes, and tectonic stability.

Evolution of DSEK technique has resulted Evolution of DSEK technique has resulted in better visual outcomes and fewer post-in better visual outcomes and fewer post-operative complications.operative complications.

DSEK has become the preferred treatment DSEK has become the preferred treatment for any endothelial dysfunction.for any endothelial dysfunction.

Purpose and DesignPurpose and DesignPurposePurpose1)1) To characterize the pattern of glaucoma progression after Descemet’s To characterize the pattern of glaucoma progression after Descemet’s

stripping endothelial keratoplasty in patients without preexisting glaucoma stripping endothelial keratoplasty in patients without preexisting glaucoma and in those with preexisting glaucoma with and without prior glaucoma and in those with preexisting glaucoma with and without prior glaucoma surgerysurgery

2)2) To compare visual outcomes among the 3 groupsTo compare visual outcomes among the 3 groups

51 DSAEK

22 Glaucoma 29 Control

12 Surgical 10 Medical

Outcome MeasuresVisual AcuityIOPSteroid doseIOP lowering medicationsRejectionGlaucoma procedures

•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

Demographics/ Baseline Characteristics

Controls (29 eyes)

Glaucoma(Medical)( 10 eyes)

Glaucoma(Surgical) (12 eyes) p values

OD:OS 16:13 7:3 5:7 0.550.55

% Caucasian 89% 100% 86% 0.070.07

% Fuchs' Endothelial Dystrophy 77% 30% 29% ..00010001

Preoperative VA (median [min, max]) 20/100 (20/25, CF)20/100 (20/25, CF) 20/400 (20/50, CF)20/400 (20/50, CF) 20/400 (20/100, CF)20/400 (20/100, CF) .003.003

Preoperative IOP (mmHg, median [min, max] 13 (8,22) 15 (12,18) 11 (5,17) .013.013

Cup-to- disc ratio 0.30 (0.2-0.65) 0.49 (0.2-0.6) 0.65 (0.35-0.9) .0001.0001

Summary of Demographics and Baseline Characteristics

21%

50%

42%

0%

10%

20%

30%

40%

50%

Perc

enta

ge o

f Pa

tient

s

Control

Glaucoma

Glaucoma Surgery

Results

0%

50%

17%5%

50%

13%

0%

10%

20%

30%

40%

50%

Perc

enta

ge o

f pat

ient

s

6 months 1 year

Control

Glaucoma

Glaucoma Surgery

13%

50%

10%

29%

67%

50%

0%

10%

20%

30%

40%

50%

60%

70%

Perc

enta

ge o

f Pat

ient

s

6 months 1 year

Control

Glaucoma

Glaucoma Surgery

p< .05 p< .05

p< .05

2 Glaucoma

Procedures

2 Surgical

0 Medical

0 Control

Initiation or Increase in Glaucoma MedicationsIncidence of IOP Elevation

Use of a Less Potent Steroid

Percentage of Control Eyes With Elevated Percentage of Control Eyes With Elevated IOPIOP

1 2 3 4 5 6 7 8 9 10 11 12

0%

2%

4%

6%

8%

10%

12%

14%

16%

Percentage of eyes

Postop (months)

Final Visual Outcomes in SubgroupsFinal Visual Outcomes in Subgroups

VA Median(min, max)

Without PreexistingGlaucoma

N=29

With PreexistingGlaucoma

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 ofimprovement 5.3 5.5 5.2 0.979

1 year compared to baseline P< 0.0001 P< 0.0001 P< 0.0001

Conclusions Conclusions Incidence of elevated IOP after DSEK:Incidence of elevated IOP after DSEK:

Without preexisting glaucoma: 21%Without preexisting glaucoma: 21%With glaucoma and no h/o surgery: 50%With glaucoma and no h/o surgery: 50%With glaucoma and prior surgery: 42%With glaucoma and prior surgery: 42%

At 1 year follow up glaucoma medication added in:At 1 year follow up glaucoma medication added in:5 % of patients without glaucoma5 % of patients without glaucoma 50 % of patients with medically managed glaucoma 50 % of patients with medically managed glaucoma 13% of patients with prior glaucoma surgery13% of patients with prior glaucoma surgery

At 1 year 17% of patients with prior surgery required an At 1 year 17% of patients with prior surgery required an additional glaucoma drainage procedure. additional glaucoma drainage procedure.

All groups gained statistically significant improvement in VA All groups gained statistically significant improvement in VA at 12 months compared with baselineat 12 months compared with baseline

ConclusionsConclusions

Given high incidence of post operative IOP Given high incidence of post operative IOP elevation, close monitoring of IOP is elevation, close monitoring of IOP is warranted.warranted.

Preexisting glaucoma does not negatively Preexisting glaucoma does not negatively affect improvement of VA after DSEK.affect improvement of VA after DSEK.

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