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Effect of Trabeculotomy on Corneal Endothelial Cell Loss in Cases of After Penetrating-Keratoplasty Glaucoma

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Effect of Trabeculotomy on Corneal Endothelial Cell Loss in Cases of After Penetrating-Keratoplasty Glaucoma CLINICAL SCIENCE Effect of Trabeculotomy on Corneal Endothelial Cell Loss in Cases of After Penetrating-Keratoplasty Glaucoma Ayaka Kusakabe, BS, MS,* Naoki Okumura, MD, PhD,* Koichi Wakimasu, MD,† Kanae Kayukawa, MD,† Masami Kondo, BS,* Noriko Koizumi, MD, PhD,* Chie Sotozono, MD, PhD,‡ Shigeru Kinoshita, MD, PhD,†‡§ and Kazuhiko Mori, MD, PhD‡ laucoma is recognized as one of the most devastating Purpose: The aim of this study was to evaluate the effect of Gcomplications that can arise after corneal transplantation, trabeculotomy (TLO) on glaucoma and endothelial cell loss after as it can often lead to corneal graft failure and glaucomatous penetrating keratoplasty (PK). optic neuropathy resulting in visual field loss. In 1969, Irvine 1 Methods: A retrospective study was conducted on consecutive patients and Kaufman reported a high incidence of intraocular who underwent PK and in whom more than 24 months of follow-up was pressure (IOP) elevation after penetrating keratoplasty (PK). available. Patients were categorized into the PK+TLO group [ie, TLO for Currently, it is widely accepted that the incidence of post-PK glaucoma (n = 10)] and the PK group [PK alone (n = 73)]. glaucoma after PK is high, ranging from 9% to 35% of all cases.2–8 Intraocular pressure (IOP) was evaluated during each follow-up fi examination. Central corneal endothelium images were obtained and Topical administration of antiglaucoma drugs is a rst- analyzed to determine corneal endothelial cell (CEC) density. line treatment for the control of IOP. However, as manage- ment of glaucoma after corneal transplantation is difficult, Results: The mean duration period from original PK to TLO for surgical treatments are often required.8 Trabeculectomy secondary glaucoma was 25.5 6 34.9 months in the PK+TLO group. (TLE), implantation of a glaucoma drainage device, and Mean preoperative IOP in the PK+TLO group was 35.8 mm Hg, and cyclophotocoagulation are the surgical procedures most decreased to 17.5 mm Hg at 24 months postoperative (P , 0.01). commonly used for the treatment of glaucoma after corneal CEC density decreased in the same manner in both groups. In the transplantation. However, they are reportedly associated with PK+TLO group, mean CEC density was 1838 cells per square a high risk of corneal endothelial cell (CEC) loss and eventual millimeter before TLO and decreased to 1195 cells per square graft failure.8,9 millimeter at 24 months after TLO. In the PK group, mean CEC Trabeculotomy (TLO) reduces IOP by improving the density decreased from 1870 to 1209 cells per square millimeter at outflow facility, and it is reportedly effective for the treatment each corresponding time point. of several types of glaucoma.10–13 However, the effectiveness of TLO for the treatment of post-PK glaucoma has yet to be Conclusions: TLO for post-PK glaucoma appeared to safely lower fully elucidated. Reportedly, one major advantage of TLO is IOP, although repeated surgeries were required in some patients, and that it is a very safe procedure without risk of bleb-related did not accelerate CEC loss. complications.14 In this study, we investigated the effect of Key Words: penetrating keratoplasty, trabeculotomy, corneal endo- TLO for the treatment of post-PK glaucoma and its influence thelial cell density on CEC loss. (Cornea 2017;36:317–321) MATERIALS AND METHODS This study was conducted in accordance with a protocol Received for publication September 11, 2016; revision received October 1, approved by the Institutional Review Board of Baptist Eye 2016; accepted October 4, 2016. Published online ahead of print Clinic, Kyoto, Japan. Clinical trial registration was obtained November 16, 2016. From the *Department of Biomedical Engineering, Faculty of Life and Medical at UMIN UMIN000021104 (http://www.umin.ac.jp/english/). Sciences, Doshisha University, Kyotanabe, Japan; †Department of In this retrospective study, we reviewed the medical records Ophthalmology, Baptist Yamasaki Eye Clinic, Kyoto, Japan; ‡Departments of consecutive patients who underwent PK at Baptist Eye of Ophthalmology; and §Frontier Medical Science and Technology for Clinic between January 2001 and October 2011 and in whom Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan. more than 24-month follow-up data were available. Patients The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations who underwent TLE, pars plana vitrectomy, or goniosyne- appear in the printed text and are provided in the HTML and PDF chialysis were excluded from the study. The included patients versions of this article on the journal’s Web site (www.corneajrnl.com). were categorized into those who underwent TLO for the Reprints: Kazuhiko Mori, MD, PhD, Department of Ophthalmology, Kyoto treatment of glaucoma after PK and those who did not Prefectural University of Medicine, 465 Kajii-cho, Hirokoji-agaru, Kawaramachi-dori, Kamigyo-ku, Kyoto 602-0841, Japan (e-mail: undergo TLO after PK (Fig. 1). Of the patients who [email protected]). underwent TLO after PK, 3 were excluded from the study Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. because of discontinuation of follow-up as a result of poor Cornea Volume 36, Number 3, March 2017 www.corneajrnl.com | 317 Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Kusakabe et al Cornea Volume 36, Number 3, March 2017 FIGURE 1. Flowchart of the patients included in the study. GSL, goniosynechial- ysis; PPV, pars plana vitrectomy. health (n = 1), failure to obtain a corneal endothelial image as The donor and recipient characteristic data are pre- a result of elevated IOP (n = 1), or not being able to undergo sented as mean 6 SD. The mean CEC loss data are presented follow-up for more than 6 months after TLO (n = 1). In the as mean 6 SE. The Student t-test was used to determine patients included in the study, anterior segments were statistical significance (P value) of the differences in the mean evaluated by slit-lamp microscopy, corneal endothelium was observed by noncontact specular microscopy (EM-3000; Tomey Corporation, Nagoya, Japan), and IOP was evaluated TABLE 1. Characteristics of the Donor and Recipient Eyes by noncontact tonometry (RKT-7700 or TONOREF2; NIDEK CO, LTD, Aichi, Japan) at each follow-up visit. PK+TLO (n = 10) PK (n = 73) P In each patient, PK was performed by first administer- Donor characteristics ing general anesthesia or retrobulbar anesthesia in accordance Age 0.47 with the patient’s overall health status. Next, partial-thickness Mean 6 SD, yrs 62.9 6 8.7 60.1 6 11.7 trephination of the host cornea was performed using a Barron Range 49–75 19–75 radial vacuum trephine (Katena Products Inc, Denville, NJ), Size 0.5 and the cornea was then excised using curved corneal Mean 6 SD, mm 7.6 6 0.3 7.6 6 0.2 scissors. Donor corneas were trephined using a Barron Range 7–7.75 7–7.75 vacuum donor cornea punch (Katena Products). In each CEC density patient, the corneal graft was sutured with 4 to 8 interrupted Mean 6 SD, cells/mm2 2756 6 338 2892 6 329 0.23 and continuous-running 10-0 nylon sutures. After PK, topical Recipient characteristics antibiotics and corticosteroid eye drops were administered Age 0.44 and then gradually tapered down. All PKs were performed by Mean 6 SD, yrs 61.0 6 16.8 64.5 6 12.7 the same surgeon (S.K.). Range 27–85 22–84 In the patients of the TLO-group, sub-Tenon capsule Sex, n (%) 0.33 anesthesia was first performed. Next, a fornix-based conjunc- Male 6 (60.0) 29 (40.8) tival flap and two 3- · 3-mm-square deep scleral flaps with Female 4 (40.0) 42 (59.2) 1/2 and 4/5 thickness were made. The outer wall of the Regraft, n (%) 4 (40.0) 0 (0.0) Schlemm canal was then dissected, and TLO probes (HS- Diagnosis, n (%) 2155B2; Handaya Co, Ltd, Tokyo, Japan) were inserted into Bullous keratopathy* 5 (50.0) 28 (38.4) the canal. A double-mirror goniolens (OMUSG; Ocular Corneal opacity 2 (20.0) 21 (28.8) Instruments Inc, Bellevue, WA) was placed on the surface Dystrophy (non-Fuchs) 1 (10.0) 13 (17.8) of the cornea to confirm insertion of the TLO probes into the Keratoconus 1 (10.0) 6 (8.2) Schlemm canal, and the probes were then rotated into the Fuchs dystrophy 1 (10.0) 3 (4.1) anterior chamber. The scleral and conjunctival flaps were then Others 1 (10.0) 2 (2.7) sutured with interrupted 10-0 nylon sutures. All TLOs were *Including edema after cataract surgery and argon-laser-iridectomy-induced edema. performed by the same surgeon (K.M.). 318 | www.corneajrnl.com Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 36, Number 3, March 2017 Effect of Trabeculotomy on Endothelial Cell Loss TABLE 2. episodes of graft rejection being observed during the 72- IOP-Lowering Effect of TLO month follow-up period. Time Post No. No. Repeated Mean IOP 6 SD, The mean preoperative IOP in the PK+TLO group was P TLO, mo Patients TLO mm Hg 35.8 6 11.3 mm Hg. After TLO, the mean IOP decreased to Preoperative 10 0 35.8 6 11.3 19.7 6 7.8 mm Hg at 6 months, 18.4 6 5.6 mm Hg at 12 6 10 3 19.7 6 7.8 0.0004 months, 16.8 6 4.9 mm Hg at 18 months, and 17.5 6 5.7 mm 12 8 4 18.4 6 5.6 0.0003 Hg at 24 months (P , 0.01).
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