Pasari Anand, Price Marianne O, Feng Matthew T, Price Francis W
Cornea Research Foundation of America, Indianapolis, IN.
Price Vision Group, Indianapolis, IN.
Cornea. 2019 Feb;38(2):151-156. doi: 10.1097/ICO.0000000000001763.
To evaluate outcomes and graft survival of Descemet membrane endothelial keratoplasty (DMEK) for failed penetrating keratoplasty (PK).
Ninety-three DMEK procedures performed in 84 eyes of 77 patients with failed PK were retrospectively reviewed. The main outcomes were corrected distance visual acuity and graft survival assessed with Kaplan-Meier survival analysis and proportional hazards modeling taking follow-up into consideration.
Sixty-nine eyes had 1 previous failed PK, 13 had 2, 1 had 3, and 1 had 4. Ten eyes had failed Descemet stripping endothelial keratoplasty (DSEK) performed under failed PK. Fourteen cases (15%) had previous glaucoma filtration surgery (9 trabeculectomy alone; 5 trabeculectomy and aqueous shunt). Median follow-up was 21 months (range, 1 month to 7 years). Median Snellen corrected distance visual acuity improved from 20/100 preoperatively (range, 20/30 to count fingers) to 20/30 at 6 months postoperatively (n = 73; range, 20/20-20/200). Rebubbling rates were 53% when the diameter of the DMEK graft was oversized, 27% when same sized, and 33% when undersized relative to that of the previous PK graft. Two grafts (2%) experienced an immunologic rejection episode, and 15 (16%) failed, including 5 primary/early failures and 10 late failures. Previous glaucoma surgery was the only significant risk factor for failure (relative risk, 7.1; 95% confidence interval, 2.1-37.0). The 1-, 2-, and 3-year graft survival rates were 96%, 89%, and 89% without versus 78%, 53%, and 39% with previous glaucoma surgery.
Treatment of failed PK with DMEK produced similar 4-year survival (76%) and better visual outcomes than previously reported with Descemet stripping endothelial keratoplasty or an initial PK regraft.
评估Descemet膜内皮角膜移植术（DMEK）治疗穿透性角膜移植术（PK）失败的疗效及植片存活率。
回顾性分析77例PK失败患者84只眼中进行的93例DMEK手术。主要观察指标为矫正远视力及植片存活率，采用Kaplan-Meier生存分析及比例风险模型并考虑随访情况进行评估。
69只眼曾有1次PK失败，13只眼有2次，1只眼有3次，1只眼有4次。10只眼在PK失败的情况下曾行Descemet膜剥除内皮角膜移植术（DSEK）但失败。14例（15%）患者曾行青光眼滤过手术（9例单纯小梁切除术；5例小梁切除术联合房水引流装置植入术）。中位随访时间为21个月（范围1个月至7年）。Snellen矫正远视力中位数从术前的20/100（范围20/30至指数）提高至术后6个月时的20/30（n = 73；范围20/20 - 20/200）。当DMEK植片直径相对于之前PK植片过大时，气泡再形成率为53%，大小相同时为27%，过小时为33%。2例（2%）植片发生免疫排斥反应，15例（16%）植片失败，包括5例原发性/早期失败和10例晚期失败。既往青光眼手术是唯一显著的失败危险因素（相对风险，7.1；95%置信区间，2.1 - 37.0）。未行既往青光眼手术者1年、2年和3年植片存活率分别为96%、89%和89%，而行过既往青光眼手术者分别为78%、53%和39%。
DMEK治疗PK失败的4年存活率（76%）与既往报道的Descemet膜剥除内皮角膜移植术或初次PK再次移植相似，但视觉效果更好。
