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

1. New York Medical College Westchester Medical Center Valhalla, NY Incidence of Cataract Extraction After Corneal Transplantation in Young and Middle-Aged Patients 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 24–60% 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

7. Results • Incidence of complications

8. Results Preexisting lens changes leading to cataract extraction 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 (n=2) • Age Group 36-51 • 3 cataract extractions • KCN, HSV, Trauma • Average of 1.4 years to CE (n=3) • 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 (n=21)

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: 113–119.  • Rathi VM, Krishnamachary M, Gupta S. Cataract formation after penetrating keratoplasty. J Cataract Refract Surg 1997; 23: 562–564.