The profile of repeated corneal transplantation

Purpose: To evaluate the primary indications for corneal transplantation in patients with repeated keratoplasties, graft survival, the causes and risk factors for failure. Setting: Tertiary referral care center. Design: Retrospective, noncomparative case series. Methods: Charts of all patients who underwent repeated corneal transplantat ion between 1985 and 1998 were reviewed. Eighty patients underwent repeated corneal transplantation, of which six underwent repeated corneal transplan tation in both eyes, totaling 86 eyes. A total of 208 keratoplasties were p erformed in this group; 86 primary and 122 repeated keratoplasties. The mos t common primary indications for corneal transplantation were vascularized corneal scar in 31 of the 86 eyes (36%), followed by pseudophakic and aphak ic bullous keratopathy (PBK, ABK). Of the repeated transplants, 55 eyes (64 %) had one repeated graft, 27 eyes (31.4%) had two repeated grafts, three ( 3.5%) had three repeated grafts, acid one (1.2%) had four repeated transpla nts. Main Outcome Measures: Final visual outcome and clarity of corneal graft. Results: At the end of the follow-up period, 44 of the 86 eyes (51%) had cl ear grafts, but only 39.5% had good visual outcome. The mean survival perio ds of the repeated transplants decreased gradually with the number of regra fting procedures, from 14.3 to 8.7 months. The mean survival period was lon ger for patients with ABK, PBK, and secondary glaucoma, and shorter for pat ients who experienced graft ulcer or surface disorders. Graft failure was u nrelated to graft size, but was associated with vascularization (P = 0.025) , additional surgical procedures (P < 0.0001), and postoperative complicati ons (P < 0.0001). There was a constant tendency for decrease in visual acui ty with time. Final visual acuity was 20/20 to 20/40 in 13 of the 86 eyes ( 15%), 20/80 to 20/200 in 23 eyes (27%), and less than 20/200 in 50 eyes (58 %). The most common complication was immune rejection, which occurred in 65 of the 208 transplants (31%), followed by secondary glaucoma in 48 eyes (2 3%) and cataract in 19 eyes (9%). Graft survival decreased remarkably after the third and forth regrafts, to 25% and 0%, respectively, compared with t he first and second regrafts, 37% and 43%, respectively. Conclusions: "High-risk" preoperative conditions, postoperative complicatio ns, and the need for additional surgical interventions may decrease graft s urvival. Close follow-up, extended use of antiinflammatory, antiviral, and immunosuppressive drugs, and avoiding additional surgical interventions as much as possible may decrease graft failure and the need for repeated kerat oplasties. (C) 2001 by the American Academy of Ophthalmology.