穿透性角膜移植术后失败行撕囊的内皮角膜移植术：视力恢复和移植物存活率。
Descemet's stripping endothelial keratoplasty under failed penetrating keratoplasty: visual rehabilitation and graft survival rate.
机构信息
Cornea Research Foundation of America, Indianapolis, Indiana; Price Vision Group, Indianapolis, Indiana, USA.
出版信息
Ophthalmology. 2011 Nov;118(11):2155-60. doi: 10.1016/j.ophtha.2011.04.032. Epub 2011 Sep 9.
PURPOSE
To evaluate graft survival, risk factors for failure, complications, and visual rehabilitation in patients who underwent Descemet's stripping endothelial keratoplasty (DSEK) under a failed penetrating keratoplasty (PK).
DESIGN
Retrospective interventional case series.
PARTICIPANTS
Sixty eyes (60 patients) treated at Price Vision Group, Indianapolis, Indiana.
METHODS
Graft diameters ranged from 8 to 9 mm and were ∼1 mm larger than the previous PK. The Descemet's membrane was not stripped in the majority (54, 84%). The graft was inserted using forceps or a Busin funnel glide (Moria, Anthony, France). The probability of graft survival was calculated by Kaplan-Meier survival analysis.
MAIN OUTCOME MEASURES
Graft survival, best-corrected visual acuity (BCVA), and complications.
RESULTS
The mean recipient age was 68 years (range, 17-95 years). Forty eyes had 1 previous failed PK, 14 eyes had 2 previous failed PKs, and 6 eyes had 3 previous failed PKs. Thirty-one eyes (52%) had preexisting glaucoma, and 16 eyes (27%) had prior glaucoma surgery (trabeculectomy in 4, shunt procedure in 12). Fifty-five grafts were performed for visual rehabilitation, and 5 grafts were performed for pain relief. Median follow-up was 2.3 years (range, 2 months to 6 years). Median preoperative BCVA was 1.23 logarithm of the minimum angle of resolution (logMAR) (range, 0.2-3, Snellen 20/340), and median postoperative visual improvement was 0.6 logMAR (6 lines), range -0.3 to +2.7. Four eyes had graft detachment (6.6%), 7 eyes (10.5%) had endothelial rejection, and 10 eyes (16.6%) had graft failure (primary failure in 2, secondary failure in 8). The overall secondary graft survival rates were 98%, 90%, 81%, and 74% at 1, 2, 3, and 4 years, respectively. Prior glaucoma shunt was the principal risk factor for graft failure. The graft survival rates were 100%, 96%, 96%, and 96% in eyes without a prior shunt versus 93%, 74%, 44%, and 22% with a prior shunt at 1, 2, 3, and 4 years, respectively (P=0.0005; relative risk = 20). Peripheral anterior synechiae (P=0.14), neovascularization (P=0.88), endothelial rejection (P=0.59), and number of prior PKs (P=0.13) were not independent risk factors for graft failure.
CONCLUSIONS
Endothelial keratoplasty under a previous failed PK is a useful alternative to a repeat standard PK, particularly in eyes with an acceptable topography and refractive outcome before failure.
FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.
目的
评估穿透性角膜移植术（PK）失败后行撕囊的内皮角膜移植术（DSEK）的移植物存活率、失败的风险因素、并发症和视力康复情况。
设计
回顾性干预性病例系列研究。
参与者
印第安纳州印第安纳波利斯市 Price Vision Group 治疗的 60 只眼（60 例）。
方法
移植物直径为 8 至 9 毫米，比之前的 PK 大约 1 毫米。大多数（54 例，84%）未撕除内皮层。使用镊子或 Busin 漏斗滑行器（Moria，Anthony，France）插入移植物。通过 Kaplan-Meier 生存分析计算移植物存活率。
主要观察指标
移植物存活率、最佳矫正视力（BCVA）和并发症。
结果
平均受者年龄为 68 岁（范围，17-95 岁）。40 只眼有 1 次先前的失败 PK，14 只眼有 2 次先前的失败 PK，6 只眼有 3 次先前的失败 PK。31 只眼（52%）有预先存在的青光眼，16 只眼（27%）有先前的青光眼手术史（4 例小梁切除术，12 例分流术）。55 只移植物用于视力康复，5 只移植物用于缓解疼痛。中位随访时间为 2.3 年（范围，2 个月至 6 年）。术前平均 BCVA 为 1.23 对数最小角分辨率（logMAR）（范围，0.2-3，Snellen 20/340），术后平均视力改善为 0.6 logMAR（6 行），范围为-0.3 至+2.7。4 只眼（6.6%）发生移植物脱离，7 只眼（10.5%）发生内皮排斥，10 只眼（16.6%）发生移植物失败（原发失败 2 只，继发失败 8 只）。整体继发性移植物存活率分别为 1 年时 98%、90%、81%和 74%，2 年时为 98%、90%、81%和 74%，3 年时为 98%、90%、81%和 74%，4 年时为 98%、90%、81%和 74%。先前有青光眼分流术是移植物失败的主要危险因素。无先前分流术的眼移植物存活率分别为 100%、96%、96%和 96%，而有先前分流术的眼分别为 93%、74%、44%和 22%，差异具有统计学意义（P=0.0005；相对风险=20）。周边前粘连（P=0.14）、新生血管形成（P=0.88）、内皮排斥（P=0.59）和先前 PK 次数（P=0.13）不是移植物失败的独立危险因素。
结论
在先前失败的 PK 下行内皮角膜移植术是重复标准 PK 的有效替代方法，特别是在失败前具有可接受的眼压和屈光结果的眼中。
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