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The Evolution of Corneal Transplantation Published: 2017.12.15 ORIGINAL PAPER e-ISSN 2329-0358 © Ann Transplant, 2017; 22: 749-754 DOI: 10.12659/AOT.905498 Received: 2017.05.25 Accepted: 2017.07.19 The Evolution of Corneal Transplantation Published: 2017.12.15 Authors’ Contribution: ABCDEF 1 Tobias Röck 1 Centre for Ophthalmology, University of Tübingen, Tübingen, Germany Study Design A DEF 1 Johanna Landenberger 2 Department of General Medicine, Ruhr-University Bochum, Bochum, Germany Data Collection B Statistical Analysis C CDEF 2 Matthias Bramkamp Data Interpretation D ACDEF 1 Karl Ulrich Bartz-Schmidt Manuscript Preparation E ABCDEF 1 Daniel Röck Literature Search F Funds Collection G Corresponding Author: Tobias Röck, e-mail: [email protected] Source of support: Departmental sources Background: The aim of this study was to investigate the evolution of surgical methods in and leading indications for cor- neal transplantation from 2005 to 2016. Material/Methods: Data from the corneal graft waiting list and from all keratoplasties carried out between 2005 and 2016 at the University Eye Hospital Tübingen were retrospectively evaluated. Results: A total of 1259 keratoplasties were performed between 2005 and 2016 at the University Eye Hospital Tübingen. The most common surgical indications for corneal transplantation were Fuchs endothelial corneal dystrophy (45.5%) and keratoconus (14.2%). The mean rate of corneal transplantations almost doubled from 71 kerato- plasties per year in the first 6-year period to 139 keratoplasties per year in the second 6-year period (P=0.005). The number of penetrating keratoplasties remained similar. The number of Descemet membrane endothelial keratoplasties (DMEK) increased significantly from 2008 to 2016 (P<0.0001). One DMEK procedure was per- formed in 2008 (representing 1.4% of all transplantations), while 75 DMEK procedures were performed in 2016 (representing 60.5% of all transplantations) (P<0.0001). DMEK became the favored surgical method for endo- thelial disorders, exceeding penetrating keratoplasty in 2013. Conclusions: Our study shows evolutionary changes in preferred corneal transplantation techniques and leading indications for keratoplasty from 2005 to 2016. Since its introduction a decade ago, DMEK is currently the golden standard in the management of corneal endothelial dysfunction. MeSH Keywords: Corneal Transplantation • Descemet Membrane • Descemet Stripping Endothelial Keratoplasty • Keratoplasty, Penetrating Full-text PDF: https://www.annalsoftransplantation.com/abstract/index/idArt/905498 1924 — 3 26 Indexed in: [Science Citation Index Expanded] [Index Medicus/MEDLINE] 749 [Chemical Abstracts] [Scopus] Röck T. et al.: ORIGINAL PAPER The evolution of corneal transplantation © Ann Transplant, 2017; 22: 749-754 Background Deep anterior lamellar keratoplasty (DALK), and Boston kera- toprosthesis]. Figure 1 shows a schematic overview display- Eduard Zirm performed the first successful corneal transplan- ing: (A) a virgin cornea and (B–F) different keratoplasty pro- tation in 1905 [1]. It is still the most frequent type of trans- cedures: (B) PK, (C) Boston keratoprosthesis, (D) DALK, (E) plantation performed in humans [2]. After Zirm’s milestone in DSAEK, and (F) DMEK. 1905, only a few improvements were made over the next 100 years, involving microscopes, sutures, antibiotics, and corti- The indications for corneal transplantation were obtained costeroids, but there was little change in the surgical tech- from the waiting list at the turn of the respective year. This niques used. However, the first decade of the 21st century study was approved by the Institutional Review Board of saw an explosion in more selective endothelial replacement the University of Tübingen and adhered to the tenets of the techniques [3]. Declaration of Helsinki. In recent years, the improvements in corneal transplantation Statistical analysis techniques have revolutionized corneal transplant surgery. The breakthrough occurred in 2006, when Melles et al. suc- Statistical analysis of the data was conducted using the cessfully introduced a new technique for transplanting isolat- Statistical Packages for the Social Sciences (SPSS 18.0). ed Descemet’s membrane (DM) through a self-sealing tunnel Quantitative variables are expressed as mean ± standard de- incision, which they referred to as DM endothelial keratoplas- viation (SD). P<0.05 was considered to be statistically signifi- ty (DMEK) [3]. cant. Descriptive statistics and graphic representations of the trend of transplantation techniques and indications were pre- In the years before DMEK was first described, different new pared. Yearly rates of corneal transplantation were compared lamellar keratoplasty techniques have been reported, includ- using the t test. ing Descemet stripping endothelial keratoplasty (DSEK) [4] and Descemet stripping automated endothelial keratoplasty (DSAEK) [5]. These procedures, especially DMEK [3,6], provide Results various benefits over penetrating keratoplasty (PK), based on its minimal invasiveness, low rate of rejection, and minimal re- Between 2005 and 2016, 1259 corneal transplantations were fractive shift, with very quick visual improvement [7]. performed at the University Eye Hospital Tübingen. These in- cluded 725 (57.6%) PKs and 534 (42.4%) lamellar keratoplasties In 2006, Darlington et al. performed a review of corneal trans- (LKs). The mean rate of keratoplasties almost doubled from plantation, analyzing data from 1980 to 2004 [8]. They found 71 corneal transplantations per year in the first 6-year period that more than 95% of corneal tissues were used for PK, and to 139 corneal transplantations per year in the second 6-year the major indications were pseudophakic bullous keratopa- period (P=0.005). thy, keratoconus, Fuchs endothelial dystrophy (Fuchs’ dystro- phy), and repeat grafts. Surgical technique Confronted with the new possibilities of lamellar keratoplas- Between 2005 and 2016, the annual numbers of PK remained ty and inspired by the investigation of Darlington et al. [8], similar. Between 2005 and 2007, keratoplasty was only carried we decided to investigate the changes in surgical methods, out in the form of PKs. The first endothelial keratoplasty (EK) the statistics on keratoplasties, and leading indications at the was carried out in 2008 using the DSAEK method. Exclusively, University Eye Hospital Tübingen from 2005 to 2016. 20 DSAEK procedures were carried out from 2008 to 2009. DMEK quickly replaced DSAEK at the University Eye Hospital Tübingen and remained the favored EK technique until now. Material and Methods One DMEK procedure was carried out in 2008 (representing 1.4% of all keratoplasties), while 75 DMEKs were carried out The medical history of all keratoplasties performed between in 2016 (representing 60.5% of all keratoplasties) (P<0.0001). January 2005 and December 2016 at the University Eye Hospital DMEK became the favored surgical method for endothelial Tübingen were retrospectively analyzed. The indications for disorders, exceeding penetrating keratoplasty in 2013. Boston transplantation were categorized according to keratoconus, keratoprosthesis, DALK, and DSAEK were performed in small Fuchs’ dystrophy, bullous keratopathy, trauma, rejection, and numbers during the 12-year period, representing 0.3%, 1.8%, others. The number of keratoplasties was determined annual- and 1.6% of the total keratoplasties, respectively. ly. The yearly numbers of performed keratoplasties were eval- uated on the basis of the surgical method [PK, DSAEK, DMEK, Indexed in: [Science Citation Index Expanded] [Index Medicus/MEDLINE] 750 [Chemical Abstracts] [Scopus] Röck T. et al.: The evolution of corneal transplantation ORIGINAL PAPER © Ann Transplant, 2017; 22: 749-754 A D B E C F Figure 1. Schematic overview displaying: (A) a virgin cornea and (B–F) different keratoplasty procedures: (B) PK, (C) Boston keratoprosthesis, (D) DALK, (E) DSAEK, and (F) DMEK. Figure 2 shows the distribution of corneal transplantations by increased significantly (P<0.0001). Fuchs’ dystrophy was the technique (PK, DSAEK, DMEK, DALK, and Boston keratoprosthe- leading surgical indication for keratoplasty from 2010 to 2016. sis) of the 1259 performed keratoplasties from 2005 to 2016. In 2005, Fuchs’ dystrophy was only the fourth most common indication (8.3%) for corneal transplantation, but in 2016 it Indications for corneal transplantation was the most common (69.5%). The indications for corneal transplantation were obtained from Figure 3 shows the distribution of the corneal graft waiting list the waiting list, which increased from 36 patients in 2005 to 246 with indications (Fuchs’ dystrophy, keratoconus, bullous kera- patients in 2016. During the study period, the leading surgical topathy, trauma, rejection, and others) for corneal transplan- indications for keratoplasties were Fuchs’ dystrophy (45.5%) tation at the turn of the year from 2005 to 2016 in 936 cases. and keratoconus (14.2%). Other indications for corneal trans- plantation were bullous keratopathy (10.4%), trauma (4.3%), rejection (8.9%), and others such as bacterial, fungal, viral or Discussion Acanthamoeba keratitis, and penetrating corneal ulcers due to trophic disease or chemical and thermal burns of the cornea Our study shows the changing trends in corneal transplantation (16.8%). In 2005, keratoconus was the most common indica- methods and leading indications for corneal transplantation tion (41.7%) for corneal transplantation, but in 2016 it was only at the University Eye Hospital in Tübingen from 2005
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