Clinical Results of Corneal Triple Procedure and Risk Factors for Graft Failure

Tae Sun Jeong; Hyung Jin Moon; In Chon You; Kyung Chul Yoon

doi:10.3341/jkos.2007.48.12.1607

Journal List > J Korean Ophthalmol Soc > v.48(12) > 1007979

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Jeong, Moon, You, and Yoon: Clinical Results of Corneal Triple Procedure and Risk Factors for Graft Failure

Original Article

J Korean Ophthalmol Soc 2007;48(12):1607-1613.

Published online: 30 August 2007

DOI: https://doi.org/10.3341/jkos.2007.48.12.1607

Clinical Results of Corneal Triple Procedure and Risk Factors for Graft Failure

Tae Sun Jeong, M.D., Hyung Jin Moon, M.D., In Chon You, M.D., Kyung Chul Yoon, M.D.

Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea

Address reprint requests to Kyung Chul Yoon, M.D., Department of Ophthalmology, Chonnam National University Medical School, #8 Hak1-dong, Dong-gu, Gwangju 501-757, Korea, Tel: 82-62-220-6742, Fax: 82-62-227-1642, E-mail: kcyoon@chonnam.ac.kr

Received 22 January 2007 Accepted 14 August 2007

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the clinical results of corneal triple procedure, as well as the causes and the risk factors for graft failure.

Methods

Indications, survival period of graft, causes of graft failure, and risk factors for failure in 29

patients (29 eyes) who had undergone penetrating keratoplasty combined with cataract surgery and intraocular lens (IOL) implantation were retrospectively analyzed.

Results

The most common primary indication of corneal triple procedure was bacterial keratitis (24%), followed by corneal trauma, herpes simplex keratitis, and graft failure. The average survival period of corneal graft in corneal triple procedure was 29.2±23.2 months. The most common cause of graft failure was allograft rejection (56.3%). The risk factors of graft failure by an univariate analysis were preoperative unfavorable diagnosis (bullous keratopathy, corneal ulcer, and trauma), corneal neovasculization, intraoperative additional procedure (anterior vitrectomy, synechiolysis, and anterior chamber irrigation), immune rejection, and postoperative glaucoma, but were unrelated to methods of cataract surgery, graft size, or IOL position.

In a multivariate analysis, graft rejection and corneal neovascularization were identified as risk factors for graft failure in patients undergoing triple procedure.

Conclusions

Corneal graft in corneal triple procedure had various success rates according to the many factors. Risk factors for graft failure included graft rejection and corneal neovascularization.

Keywords: Corneal triple procedure, Graft failure, Risk factor

References

1. Davis EA, Stark WJ. The triple procedure-is it the best approach for the patient? The triple procedure may be superior to sequential surgery. Arch Ophthalmol. 2000; 118:414–5.

2. Inoue Y. Corneal triple procedure. Semin Ophthalmol. 2001; 16:113–8.

3. Kim SM, Sae WJ, Kim JH. Combined keratoplasty and cataract surgery. J Korean Ophthalmol Soc. 1995; 36:1669–76.

4. Cho EH, Tchah HW. Clinical result of penetrating keratoplasty combined with intraocular lens implantation or exchange. J Korean Ophthalmol Soc. 1996; 37:2031–40.

5. Bersudsky V, Rehany U, Rumelt S. Risk factors for failure of simultaneous penetrating keratoplasty and cataract extraction. J Cataract Refract Surg. 2004; 30:1940–7.

6. Hamil MB. The triple procedure-is it the best approach for the patient? Sequential surgery may be the best approach for the patients (controversies). Arch Ophthalmol. 2000; 118:415–7.

7. Sanford DK, Klesges LM, Wood TO. Simultaneous penetrating keratoplasty, extra -capsular cataract extraction, and intraocular lens implantation. J Cataract Refract Surg. 1991; 17:824–9.

8. Weisbrod DJ, Sit M, Naor J, Slomovic AR. Outcomes of repeat penetrating keratoplasty and repeat penetrating keratoplasty and risk factors for graft failure. Cornea. 2003; 22:429–34.

9. Sit M, Weisbrod DJ, Naor J, Slomovic AR. Corneal graft outcome study. Cornea. 2001; 20:129–33.

10. Yoon KC, Park YK, Park YG. Surgical results of repeat penetrating keratoplasty and risk factors for graft failure. J Korean Ophthalmol Soc. 2004; 45:1827–32.

11. Kim SM, Sae WJ, Kim JH. Combined keratoplasty and cataract surgery. J Korean Ophthalmol Soc. 1995; 36:1669–76.

12. Sridhar MS, Murthy S, Bansal AK, Rao GN. Corneal triple procedure: indications, complications, and outcomes. Cornea. 2000; 19:333–5.

13. Katzin HM, Meltzer JF. Combined surgery for corneal transplantation and cataract extraction. Am J Ophthalmol. 1996; 556–60.

14. Taylor DM. Keratoplasty and intra-ocular lenses. Ophthalmic Surg. 1976; 7:31–42.

15. Heidemann DG, Dunn SP. Visual results and complications of transsclerally sutured intraocular lenses in penetrating keratoplasty. Ophthalmic Surg. 1990; 21:609–14.

16. Heidemann DG, Dunn SP. Transsclerally sutured intraocular lenses in penetrating keratoplasty. Am J Ophthalmol. 1992; 113:619–25.

17. Yamaguchi S, Suzuki Y, Tsuru T. Risk factors for graft failure in penetrating keratoplasty. Acta Ophthalmol Scand. 1996; 74:584–8.

18. Lomholt JA, Ehlers N. Graft survival and risk factors of penetrating keratoplasty for microbial keratitis. Acta Ophthalmol Scand. 1997; 75:418–22.

19. Inoue K, Amaos S, Oshika T, Tsuru T. Risk factors for corneal graft and rejection in penetrating keratoplasty. Acta Ophthalmol Scand. 2001; 79:251–5.

20. Jonas JB, Rank RM, Budde WM, Sauder G. Factors influencing visual outcome after penetrating keratoplasty combined with intraocular lens implantation. Eur J Ophthalmol. 2003; 13:134–8.

21. Williams KA, Esterman AJ, Bartlett C, et al. How effective is penetrating corneal transplantation? Factors influencing long-term outcome in multivariate analysis. Transplantation. 2006; 81:896–901.

22. Maquire MG, Stark WJ, Gottsch JD, et al. Risk factors for corneal graft failure and rejection in the collaborative corneal transplantation studies. Collaborative Corneal Transplantation Studies Research Group. Ophthalmology. 1994; 101:1536–47.

23. Borderie VM, Touzeau O, Bourcier T, et al. The triple procedure: in the bag placement versus ciliary sulcus placement of the intraocular lens. Br J Ophthalmol. 1999; 83:458–62.

Figure 1.

The distribution of preoperative diagnosis in corneal triple procedure.

* HSK : herpes simplex keratitis.

^† SJS : Stevens-Johnson syndrome.

Figure 2.

Kaplan-Meier cumulative survival proportional curve of corneal grafts in corneal triple procedure.

Table 1.

Causes of graft failure in corneal triple procedure

Causes	No. of patients (%)
Allograft rejection	9 (56.3)
Bullous keratopathy	3 (18.8)
Postoperative glaucoma	2 (12.5)
Endothelial failure	1 (6.2)
Recurrence of host disease	1 (6.2)
Total	16 (100)

Table 2.

Univariate analysis of risk factors for graft failure in corneal triple procedure

Factors	No. of patients (%)		P-value
Factors	Graft success	Graft failure	P-value
Preoperative diagnosis
Favorable^*	7 (53.8)	3 (18.8)	0.02
Unfavorable^†	6 (46.2)	13 (81.2)	0.02
Corneal neovasculization
Presence	4 (30.8)	10 (62.5)	<0.01
Absence	9 (69.2)	6 (37.5)	<0.01
Methods of cataract surgery
Planned ECCE^‡	9 (69.2)	8 (50.0)
Phacoemulsification	3 (23.1)	2 (12.5)	0.15
ICCE^§	1 (7.7)	6 (37.5)
Intraoperative additional intervention
Presence	5 (46.2)	11 (68.7)	0.04
Absence	8 (53.8)	5 (31.3)	0.04
Donor size
< 7.5 mm	1 (0.09%)	2 (11.1%)
≥ 7.5 mm, < 8.0 mm	8 (72.7%)	6 (33.3%)	0.10
≥ 8.0 mm	2 (0.18%)	10 (55.5%)
Immune rejection
Presence	3 (23.1)	13 (81.3)	0.03
Absence	10 (76.9)	3 (18.7)	0.03
Postoperative glaucoma
Presence	3 (23.1)	9 (56.3)	0.04
Absence	10 (76.9)	7 (43.7)	0.04
IOL^π position
In the bag	9 (69.2)	10 (62.5)	0.71
Sulcus or scleral fixation	4 (30.8)	6 (37.5)	0.71

^* Favorable diagnosis includes keratoconus and corneal dystrophy.

^† Unfavorable diagnosis includes bacterial ulcer, herpes simplex keratitis, graft failure, corneal scar and Stevens-Johnson syndrome.

^‡ ECCE: extracapsular cataract extraction,

^§ ICCE: intracapsular cataract extraction.

^π IOL: intraocular lens.

Table 3.

Multivariate analysis of risk factors for graft failure in corneal triple procedure

Risk factor	P-value	Relative risk	95% CI^*
Risk factor	P-value	Relative risk	Lower	Upper
Unfavorable diagnosis	0.12	1.99	2.28	5.09
Immune rejection	0.03	4.51	1.11	13.11
Postoperative glaucoma	0.50	0.46	0.48	4.45
Preoperative corneal neovasculization	0.02	5.32	1.28	16.17
Graft size ≥ 8.0mm	0.40	0.72	0.81	4.82
Intraoperative additional intervention	0.34	0.90	0.13	2.05
Sulcus or scleral fixation of IOL^†	0.29	0.88	0.61	4.80

^* 95% confidence interval;

^† IOL=intraocular lens.

TOOLS

Similar articles