Incidence of Cataract Extraction After Corneal Transplantation in Young and Middle-Aged Patients

1
Incidence of Cataract Extraction After Corneal
Transplantation in Young and Middle-Aged Patients
New York Medical College Westchester Medical
Center Valhalla, NY

• Revathi Naadimuthu, MD
• Gerald W. Zaidman, MD
• Brandon Mirochnik, BA
• Tehara Bailey, BA

Authors have no financial interest to disclose.
2
Introduction

• In patients requiring corneal transplantation and
  cataract extraction there is debate as to how it
  should be performed
• Triple procedure - simultaneous cataract
  extraction (CE), lens implantation and
  penetrating keratoplasty (PKP/DSEK)
• Keratoplasty followed by CE with lens
  implantation
• Cataract extraction followed by keratoplasty

3
Purpose

• Cataract formation has been found to develop in
  2460 of all patients after a single penetrating
  keratoplasty.
• This study will
• Determine the incidence of cataract formation in
  younger and middle-aged patients, aged 25 65
  years old, who required penetrating keratoplasty.
• Determine the various risk factors associated
  with cataract formation.

4
Methods

• A retrospective chart review was performed on 195
  penetrating keratoplasty cases performed by a
  single surgeon between December 1997 and January
  2007 in a tertiary care setting, with an average
  follow up time of 4 years following corneal
  transplantation.
• The cases were reviewed for the presence of
  cataracts following transplant, and the
  etiologies leading to corneal transplantation.
• The patients were divided into three groups by
  age
• 25-35 years old
• 36-50 years old
• 51-65 years old
• Each group was then analyzed for incidence of
  cataract formation
• Cataract formation did not occur
• Cataract formation occurred
• The factors analyzed were
• Preoperative diagnosis
• Age
• Complications following PKP-rejection, glaucoma,
  regrafts
• Pre-existing lens opacity
• Length of time to cataract formation

5
Results

• The most common diagnoses included
• Keratoconus (65)
• Fuchs' dystrophy (10)
• HSV keratitis leading to corneal scarring (8)
• Other corneal dystrophies (7)
• Trauma (4)
• Post-refractive surgery ectasia (3)

6
Results
Diagnosis Leading to PKP by Age
Age 25-35 (n58) Age 25-35 (n58)
KCN 48 (83)
Trauma 4 (6)
HSV 2 (3)
Corneal dystrophy 2 (3)
Refractive ectasia 1 (2)
Scar, Ulcer 1 (2)
Age 36-50 (n82) Age 36-50 (n82)
KCN 54 (66)
Dystrophy 8 (10)
Refractive Ectasia 5 (6)
HSV 4 (5)
Trauma 4 (5)
Ulcer 2 (2)
Corneal Edema 2 (2)
Fuchs 2 (2)
Exposure, scar 1 (1)
Age 51-65 (n55) Age 51-65 (n55)
KCN 21 (38)
Fuchs 17 (31)
HSV 8 (15)
Dystrophy 4 (7)
Corneal Edema 1 (2)
Ulcer 1 (2)
7
Results

• Incidence of complications

CATARACT FORMATION NO CATARACT FORMATION
Rejection 37.5 32
AGE 25-35 ? IOP 0 2
Regrafts 0 2
Rejection 42 29
AGE 36-50 ? IOP 6 2
Regrafts 12 2
Rejection 24 17
AGE 51-65 ? IOP 8 0
Regrafts 10 0
8
Results
Preexisting lens changes leading to
cataract extraction
AGE GROUP PREEXISTING LENS CHANGES CATARACT EXTRACTION
25-35 (n58) 2 (3) 1 (1.7)
36-50 (n82) 6 (7) 2 (2.4)
51-65 (n55) 38 (69) 18 (33)
Of all patients, 46 had preexisting
cataract, while only 13 went on to require
cataract extraction
9
Results

• CATARACT EXTRACTIONS
• Age Group 25-35
• 2 cataract extractions
• Both in KCN patients
• Average of 4 years to CE (n2)
• Age Group 36-51
• 3 cataract extractions
• KCN, HSV, Trauma
• Average of 1.4 years to CE (n3)
• Age Group 51-65
• 21 cataract extractions
• 9 (53) of all patients with Fuchs' required CE
• Patients with Fuchs and prior cataracts had a 64
  incidence of CE
• 5 (63) of patients with HSVK required CE
• 1 (5) of patients with KCN required CE
• Average 1.98 years to CE (n21)

Diagnosis No. of Patients Required CE
KCN 132 6 (5)
Fuchs' 19 9 (47)
HSVK 15 8 (53)
Lattice 12 2 (17)
10
Results

• The major factors affecting cataract formation
  were the diagnosis leading to corneal transplant
  and age
• 47 of patients who formed cataracts had a
  post-operative complication while complications
  were only seen in 36 of patients who did not
  form cataracts, but this difference was not
  statistically significant
• Average age was lower in the groups that did not
  form cataracts vs. those that required CE (37
  y.o. vs. 58 y.o.)
• Total Cataract Extractions 26
• 81 were over age 51
• 81 had preexisting lens opacities
• Diagnosis
• The most common diagnosis in patients who did not
  require cataract extraction was KCN
• In patients who required cataract extraction, the
  most common diagnosis was Fuchs' dystrophy
  followed by HSV keratitis

11
Conclusion

• The age of the patient was related to incidence
  of cataract formation and extraction.
• KCN was associated with the least incidence of
  cataract formation , while Fuchs Dystrophy
  followed by HSV keratitis were associated with
  the highest incidence of cataract formation and
  extraction.
• Any one complication alone (e.g. history of
  rejection, high IOP, graft failure requiring a
  2nd graft) did not significantly contribute to CE
• Even when controlled for age, patients with Fuchs
  had a 53 incidence of CE, compared to 5
  incidence of CE in patients with KCN

12
Conclusion

• Implications and counseling patients
• Risk of requiring cataract extraction is greatest
  in patients over age 51
• 33 required cataract extraction
• In this population the risk is even greater in
  patients with a diagnosis of Fuchs' dystrophy
• Risk is also great in patients with a diagnosis
  of HSV keratitis 53 incidence of CE
• Complications such as rejection episodes and
  elevated IOP did not significantly affect the
  necessity for cataract extraction
• Surgeons should be aware that many patients aged
  51-65 that require keratoplasty have a chance of
  needing cataract surgery
• Martin TP, Reed JW, Legault C, Oberfeld SM,
  Jacoby BG, Yu DD et al. Cataract formation and
  cataract extraction after penetrating
  keratoplasty. Ophthalmology 1994 101 113119. 
• Rathi VM, Krishnamachary M, Gupta S. Cataract
  formation after penetrating keratoplasty. J
  Cataract Refract Surg 1997 23 562564.