Tóth Gábor, Váncsa Szilárd, Kói Tamás, Kormányos Kitti, Hegyi Péter, Szentmáry Nóra
From the Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research (G.T., N.S.), Saarland University, Homburg/Saar, Germany.
Centre for Translational Medicine (S.V., T.K., P.H.), Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases (S.V., P.H.), Semmelweis University, Budapest, Hungary.
Am J Ophthalmol. 2025 Aug;276:218-229. doi: 10.1016/j.ajo.2025.04.017. Epub 2025 Apr 19.
To compare surgical outcomes following penetrating keratoplasty (PK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet membrane endothelial keratoplasty (DMEK) in patients with iridocorneal endothelial (ICE) syndrome.
Systematic review and meta-analysis on individual patient data (IPD).
Pre-registration was performed in the PROSPERO database (registration number: CRD42024539444). Eligible studies from Embase, MEDLINE (via PubMed), and the Cochrane Central Register of Controlled Trials (CENTRAL) were retrieved up to April 24, 2024. Studies were included those reporting clinical outcomes after PK, DSEK, or DMEK- graft survival, best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) - in people with ICE syndrome. Cochrane Handbook was followed for data extraction/ synthesis, and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) and the Joanna Briggs Institute Critical Appraisal Checklists were used to assess risk of bias. Meta-analyses were conducted using a random-effects model. Heterogeneity between studies was assessed using Q-test and I statistics.
Nineteen of the 1963 screened studies were included in the meta-analysis. Multivariate pooled Kaplan-Meier curves with 95% confidence intervals, based on IPD from studies with at least 10 cases indicated that graft survival was better after PK compared to DSEK in patients with ICE syndrome. No significant difference (P = .92) was found in BSCVA improvement between PK [-0.77 (95% CI, -1.45 to -0.09)], DSEK [-0.87 (95% CI, -1.35 to -0.39)] and DMEK [-0.85 (95% CI, -1.07 to -0.62)]. No significant differences in ECD were observed between DSEK and DMEK 6 (P = .88) and 12 months (P = .33) postoperatively. IPD analysis revealed no significant difference in graft survival between patients with and without anytime glaucoma (-0.04 ± 0.50 SEM; P = .940) or cataract surgery (-0.45 ± 0.40 SEM; P = .265).
PK demonstrated better graft survival compared to DSEK in patients with ICE, however, further research and additional evidence are needed to draw more definitive conclusions. Improvements in BSCVA were comparable across PK, DSEK and DMEK. Glaucoma surgery, whether performed before or after keratoplasty, appear to have no significant impact on graft survival.
比较穿透性角膜移植术（PK）、后弹力层剥除内皮角膜移植术（DSEK）和后弹力层内皮角膜移植术（DMEK）治疗虹膜角膜内皮（ICE）综合征患者的手术效果。
对个体患者数据（IPD）进行系统评价和荟萃分析。
在PROSPERO数据库（注册号：CRD42024539444）进行预注册。检索截至2024年4月24日Embase、MEDLINE（通过PubMed）和Cochrane对照试验中央注册库（CENTRAL）中的符合条件的研究。纳入报告ICE综合征患者接受PK、DSEK或DMEK术后临床结局（植片存活率、最佳矫正视力[BSCVA]和内皮细胞密度[ECD]）的研究。按照Cochrane手册进行数据提取/合成，并使用干预性非随机研究的偏倚风险（ROBINS-I）和乔安娜·布里格斯研究所批判性评价清单评估偏倚风险。采用随机效应模型进行荟萃分析。使用Q检验和I统计量评估研究间的异质性。
1963项筛查研究中有19项纳入荟萃分析。基于至少有10例病例的研究的IPD绘制的多变量合并Kaplan-Meier曲线及95%置信区间表明，ICE综合征患者接受PK后的植片存活率优于DSEK。PK[-0.77（95%CI，-1.45至-0.09）]、DSEK[-0.87（95%CI，-1.35至-0.39）]和DMEK[-0.85（95%CI，-1.07至-0.62）]之间在BSCVA改善方面未发现显著差异（P = 0.92）。术后6个月（P = 0.88）和12个月（P = 0.33）时，DSEK和DMEK之间的ECD无显著差异。IPD分析显示，有和没有任何时候青光眼的患者之间（-0.04±0.50 SEM；P = 0.940）或白内障手术患者之间（-0.45±0.40 SEM；P = 0.265）在植片存活率方面无显著差异。
ICE综合征患者中PK的植片存活率优于DSEK，然而，需要进一步研究和更多证据才能得出更明确的结论。PK、DSEK和DMEK在BSCVA改善方面相当。青光眼手术，无论在角膜移植术前还是术后进行，似乎对植片存活率均无显著影响。
