Results of Penetrating Keratoplasty For Aphakic And Pseudophakic Bullous Keratopathy

RESULTS O F PENETRATING KERATOPLASTY FOR APHAKIC A N D P S E U D O P H A K I C BULLOUS KERATOPATHY D A V I D J. S C H A N Z L I N , M . D . , D E B O R A H S. G O M E Z , B.A.,

J E F F R E Y B. R O B I N ,

J O S E P H J. G I N D I , M . D . , Los Angeles,

M.D.,

AND R O N A L D E. S M I T H ,

M.D.

California

We retrospectively studied 61 consecutive cases of penetrating keratoplasty performed for aphakic bullous keratopathy or pseudophakic bullous keratopathy. After keratoplasty, the mean visual acuities of both groups of patients improved significantly from preoperative levels (P < .0001). One year after keratoplasty, 18 eyes had visual acuities of 20/40 or better. Twelve of the 24 eyes followed up for at least two years after surgery had visual acuities of 20/40 or better. The mean visual acuities for the eyes with aphakic bullous keratopathy and the eyes with pseudophakic bullous keratopathy were not significantly different at either one or two years after keratoplasty. Cystoid macular edema (11 eyes) and glaucoma (12 eyes) were the most common causes of visual acuities worse than 20/40. There were no significant differences in the incidences of these complications in the group with aphakic bullous keratopathy and in the group with pseudophakic bullous keratopathy. Intraocular lens removal did not significantly affect either visual acuity or macular complications after keratoplasty. Corneal decompensation after cataract extraction has become the most common indication for penetrating keratoplasty. 1 " 3 Factors that have contributed to the in­ creased incidence of bullous keratopathy after cataract extraction include an in­ crease in the number of lens extractions performed and the decrease in the age limits of patients undergoing these proce­ dures. 4,5 The most significant contributo­ ry factor, however, has been the wide­ spread implantation of intraocular lenses.1·3,6·7 Early studies noted that the prognosis

Accepted for publication July 12, 1984. From the Estelle Doheny Eye Foundation, De­ partment of Ophthalmology, University of Southern California, Los Angeles, California. This study was supported in part by an award from Research to Prevent Blindness, Inc., New York, New York. Reprint requests to David J. Schanzlin, M.D., 1355 San Pablo St., Los Angeles, CA 90033. 302

for visual recovery after penetrating kera­ toplasty performed for aphakic bullous keratopathy was poor.8"12 Although recent reports have documented clear grafts in more than 75% of cases, the incidence of visual acuities of 20/40 or better after keratoplasty was only 15% to 40%.2·13"16 Similarly, studies of penetrating kerato­ plasty performed for pseudophakic bul­ lous keratopathy have noted clear grafts in more than 85% of cases; despite this, the incidence of visual acuities of 20/40 or better was only 16% to 54%.3,15"20 The three most common causes cited for poor visual acuity after corneal transplantation for either aphakic bullous keratopathy or pseudophakic bullous keratopathy are cystoid macular edema, graft failure, and glaucoma.2,3,13"22 To define better the visual prognosis and incidence of complications after kera­ toplasty, we conducted a retrospective analysis of 61 consecutive cases of pen-

©AMERICAN JOURNAL OF OPHTHALMOLOGY 98:302-312, 1984

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trating keratoplasty performed for aphakic bullous keratopathy or pseudophakic bullous keratopathy. S U B J E C T S AND M E T H O D S

The study included all patients at the Estelle Doheny Eye Foundation who un­ derwent penetrating keratoplasty for aphakic bullous keratopathy or pseudo­ phakic bullous keratopathy between Jan­ uary 1980 and August 1983. A total of 61 eyes in 59 patients under­ went corneal transplantation for either aphakic bullous keratopathy or pseudo­ phakic bullous keratopathy during the study period. The mean age of this pa­ tient population was 71.7 years. Nineteen of the patients (32%) were men and 40 (68%) were women. Thirty-eight of the 61 transplants (62%) were performed on right eyes and 23 (38%) were performed on left eyes. The group with aphakic bullous kera­ topathy consisted of 27 eyes in 26 pa­ tients. Sixteen of these patients (64%) were women and nine (36%) were men. The mean age for this group was 72.5 years. Fourteen of these 27 transplants (52%) were performed on right eyes and 13 (48%) on left eyes. Thirty-four corneal transplants were performed for pseudophakic bullous ker­ atopathy in 33 patients. There were 24 women (73%) and nine men (27%). Their mean age was 70.9 years. Twenty-four (71%) of these transplants involved right eyes and ten (29%) were performed on left eyes. Cataract extraction—Of the 27 eyes with aphakic bullous keratopathy, 23 (85%) had previously undergone intra­ capsular cataract extraction, three (12%) had had extracapsular cataract extraction, and one (4%) had had pars plana lensectomy. The mean time from cataract extrac­ tion to penetrating keratoplasty was 82.8 months and the mean time from onset of decreased visual acuity after cataract ex­

303

traction to corneal transplantation was 46.1 months. Nineteen of the 34 eyes with pseudo­ phakic bullous keratopathy (56%) had previously undergone intracapsular cata­ ract extraction with iris-supported intra­ ocular lens implantation. Eight eyes (24%) had had intracapsular cataract ex­ traction with anterior chamber intraocu­ lar lens implantation, two (6%) had had extracapsular extraction with posterior chamber intraocular lens implantation, one (3%) had had extracapsular extraction with anterior chamber intraocular lens implantation, and one (3%) had had extra­ capsular extraction with iris-supported intraocular lens implantation. Three eyes (9%) had undergone intraocular lens re­ moval before referral; all of these were iris-supported lenses. The mean time from cataract extraction to penetrating keratoplasty in the group with pseudo­ phakic bullous keratopathy was 45.6 months and the mean time from onset of decreased visual acuity after cataract ex­ traction to corneal transplantation was 23.4 months. Surgical technique—The penetrating keratoplasties were performed in the rou­ tine manner by two surgeons (D.J.S. and R.E.S.). All eyes received a 0.5-mm oversized donor corneal graft trephined from the endothelial side. All donor cor­ neas were stored in M cCarey-Kaufman medium and were used within 72 hours after enucleation. Suturing techniques involved one of the following: 16 inter­ rupted 10-0 nylon sutures, a 16-bite run­ ning 10-0 nylon suture, or a 16-bite run­ ning 10-0 Prolene suture. Of the 61 penetrating keratoplasties we studied, 51 (84%) had been done with concomitant anterior vitrectomies. Twenty-two of the 27 eyes with aphakic bullous keratopathy (81%) and 29 of the 34 eyes with pseudophakic bullous kera­ topathy (85%) had this procedure. All vitrectomies were performed with auto-

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mated instrumentation. Additionally, three of the eyes with aphakic bullous keratopathy (11%) and four of the eyes with pseudophakic bullous keratopathy (12%) had had anterior vitrectomies per­ formed before referral for penetrating keratoplasty. Therefore, 25 of the 27 eyes with aphakic bullous keratopathy (92%), 33 of the 34 eyes with pseudophakic bullous keratopathy (97%), and 58 of the combined total of 61 eyes (95%) had ante­ rior vitrectomies. Intraocular lenses were removed at the time of penetrating keratoplasty" in 24 of 34 eyes with pseudophakic bullous kera­ topathy (71%). The intraocular lenses were removed if they were dislocated, if there was intraocular lens-cornea touch, or if there was severe ocular inflamma­ tion. Nineteen of the 27 eyes (70%) in which the intraocular lenses were re­ moved during or before penetrating kera­ toplasty had iris-supported intraocular lenses, seven (26%) had anterior chamber intraocular lenses, and one (4%) had a posterior chamber intraocular lens. The intraocular lenses were not removed in seven of the 34 eyes with pseudophakic bullous keratopathy (20%); of these, four had anterior chamber intraocular lenses, two had iris-supported intraocular lenses, and one had a posterior chamber intraoc­ ular lens. Statistical analysis—To compare mean visual acuities between groups, we con­ verted them into decimal functions. For purposes of clarity, however, we report­ ed mean visual acuities as the closest Snellen visual acuity equivalent. We ana­ lyzed differences in mean visual acuities by means of two-tailed ί-tests, with a significance level of P < .05. We used χ2 tests with the Yates correction to analyze complication rates; again, a level of P < .05 determined significance. RESULTS

Preoperative visual acuity—Preoperatively, none of the 61 eyes had visual

SEPTEMBER, 1984

acuities better than 20/60. The mean preoperative visual acuity for all of the eyes included in this study was between 20/400 and counting fingers. The mean preoperative visual acuities for the eyes with aphakic bullous keratopathy and those with pseudophakic bullous kera­ topathy were not significantly different. Co-existing ocular conditions—Addi­ tional ocular pathologic conditions pres­ ent in the 27 eyes with aphakic bullous keratopathy at the time of corneal trans­ plantation included 11 cases of glaucoma (42%), ten of cystoid macular edema (38%), and three with senile macular de­ generation (12%). For the purposes of this study, we defined glaucoma as an in­ crease in intraocular pressure requiring medical or surgical therapy. Both cystoid macular edema and senile macular de­ generation were defined on the basis of biomicroscopic or fluorescein angio­ graphie findings. Thirteen eyes (50%) had vitreocorneal touch at the time of pene­ trating keratoplasty, and two (8%) had previously undergone anterior vitrectomy to correct vitreocorneal touch. Of the 34 eyes with pseudophakic bul­ lous keratopathy, 15 (44%) had glaucoma, 11 (32%) had cystoid macular edema, and two (6%) had senile macular degenera­ tion. Seven eyes (21%) had vitreocorneal touch at the time of keratoplasty. Three of the 11 eyes with pseudophakic bullous keratopathy and cystoid macular edema (27%) also had vitreocorneal touch. Addi­ tionally, five of the 34 eyes with pseudo­ phakic bullous keratopathy (15%) had dis­ located intraocular lenses; two of these eyes had intraocular lens-cornea touch. Postoperative follow-up—Fifty-two of the 61 eyes (85%) were followed up for at least one year after transplantation. These included 21 of the 27 eyes with aphakic bullous keratopathy (78%) and 31 of the 34 eyes with pseudophakic bullous keratopathy (91%). Twenty-four of the 61 eyes (39%) were followed up for at least two years postoperatively, including 11 of

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KERATOPLASTY IN BULLOUS KERATOPATHY

the 27 eyes with aphakic bullous keratop­ athy (41%) and 13 of the 34 eyes with pseudophakic bullous keratopathy (38%). The mean follow-up time for the entire study was 1.8 years. Graft clarity—Fifty-seven of the 61 transplants (93%) remained clear. All 27 transplants performed for aphakic bullous keratopathy remained clear; of the 34 transplants for pseudophakic bullous ker­ atopathy, 30 (88%) remained clear. Of the four graft failures in pseudophakic bul­ lous keratopathy, two occurred in eyes with anterior chamber intraocular lenses and two in eyes with iris-supported intra­ ocular lenses. In three of the eyes with graft failure the intraocular lenses were removed either during or before corneal transplantation; in the fourth eye the iris-supported intraocular lens was left in place. Visual acuity one year after keratoplasty—Of the 52 eyes followed up for at least one year after corneal trans­ plantation, all but seven had improved visual acuities compared to preoperative levels. The mean visual acuity for all eyes one year after surgery was 20/60; 18 of these eyes (37%) had visual acuities of 20/40 or better (Table 1).

305

In the 22 eyes with aphakic bullous keratopathy tested one year postoperatively, the mean visual acuity was 20/50; eight of these eyes (38%) had visual acui­ ties of 20/40 or better. The mean visual acuity for the 19 eyes with aphakic bul­ lous keratopathy that underwent intracapsular cataract extraction was 20/50; for the three eyes with aphakic bullous kera­ topathy that underwent extracapsular ex­ traction, the mean visual acuity was 20/80. Thirty-one of the 34 eyes with pseudo­ phakic bullous keratopathy were followed up for at least one year after corneal transplantation. The mean visual acuity for these eyes was 20/70; ten of these eyes (32%) had visual acuities of 20/40 or bet­ ter. When we examined visual acuities and intraocular lens location, we found that the ten eyes with anterior chamber intraocular lenses had a mean visual acu­ ity of 20/60, the two eyes with posterior chamber intraocular lenses had a mean visual acuity of 20/30, and the 20 eyes with iris-supported intraocular lenses had a mean visual acuity of 20/80. The mean visual acuities for both the group with aphakic bullous keratopathy and the group with pseudophakic bullous

TABLE 1 VISUAL ACUITY ONE YEAR AFTER KERATOPLASTY Bullous Keratopathy Pseudophakic

Aphakic

Visual Acuity

20/20 20/30 20/40 20/60 20/80 20/100 20/200 CF. H.M. Mean

All Eyes

Intracapsular

Extracap­ sular

No.

%

No.

No.

3 4 11 13 2 0 8 3 1

5 7 21 25 4 0 15 6 2

20/60

%

11 11 21 25 5 0 16 5 0 20/50

%

0 0 0 50 0 0 50 0 0 20/100

All No.

%

10 10 20 30 5 0 20 5 0 20/50

Anterior Chamber

Posterior Chamber

No.

No.

%

0 11 44 11 0 0 0 11 0 20/60

%

0 0 50 1 1 50 0 0 0 0 0 0 0 0 0 0 0 0 20/30

IrisSupported No.

%

o 0 10 30 3 0 20 5 5

20/80

All No.

%

3 6 23 23 5 0 13 6 3 20/70

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keratopathy improved significantly from preoperative levels (P < .0001). There was, however, no significant difference between the two groups. Visual acuity two years after keratoplasty—Twenty-four of the 61 eyes in this study were followed up for at least two years after corneal transplantation. The mean visual acuity for these eyes was 20/50 and 12 of the eyes had visual acui­ ties of 20/40 or better. Of the 11 eyes with aphakic bullous keratopathy followed up for at least two years, the mean visual acuity was 20/40; six of these eyes had visual acuities of 20/40 or better. Of these 11 eyes, ten had previously undergone intracapsular cata­ ract extraction; the one eye that had undergone extracapsular extraction had a visual acuity of 20/400. Thirteen of the 34 eyes with pseudophakic bullous keratopathy were followed up for at least two years after transplanta­ tion. The mean visual acuity for these eyes was 20/60; five of these eyes (38%) had visual acuities of 20/40 or better. The two eyes with anterior chamber intraocu­ lar lenses had visual acuities of counting fingers. The one eye with a posterior chamber intraocular lens had a visual acuity of 20/20. The ten eyes with iris-

SEPTEMBER, 1984

supported intraocular lenses had a mean visual acuity of 20/70. Again, the mean visual acuities for both the eyes with aphakic bullous keratop­ athy and the eyes with pseudophakic bul­ lous keratopathy two years after kerato­ plasty were significantly improved from preoperative levels (P < .0001), but there was not a significant improvement from the one-year levels. Again, the mean visual acuities of the two groups did not differ significantly either one or two years postoperatively. Postoperative complications—Nine­ teen of the 61 eyes (31%) studied had cystoid macular edema postoperatively (Table 2); of these, seven had first devel­ oped cystoid macular edema before ker­ atoplasty, while 12 developed it post­ operatively. Eight of the 27 eyes (30%) with aphakic bullous keratopathy had cys­ toid macular edema after keratoplasty; in five of these eyes, the cystoid macular edema had first developed before sur­ gery. Seven of the eight cases were in eyes with previous intracapsular cataract extraction; the eighth occurred in an eye with previous extracapsular extraction. There was no significant difference be­ tween the incidences of cystoid macular edema in the eyes with aphakic bullous

TABLE 2 COMPLICATIONS A F T E R KERATOPLASTY

Primary Surgery

Intracapsular extraction Extracapsular extraction Pars plana lensectomy Total Iris-s\ipported irhplant Anterior chamber implant Posterior chamber implant Total

Cystoid Macular Edema No.

Glaucoma No.

Graft Failure No.

7 1 0 8

Aphakic Bullous Keratopathy (No. = 27) 26 10 38 0 4 3 11 0 0 1 4 0 30 14 52 0

10 1 0 11

Pseudophakic Bullous Keratopathy (No. = 34) 29 10 30 2 3 7 21 2 0 1 3 0 32 18 53 4

'Percentage of eyes in affected subgroup compared with total number of eyes in each group.

6 6 0 12

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postoperative glaucoma, but only five first developed glaucoma after keratoplas­ ty. The incidences of postoperative glau­ coma were 45% (ten of 22) in eyes with iris-supported intraocular lenses, 70% (seven often) in eyes with anterior cham­ ber intraocular lenses, and 50% (one of two) in eyes with posterior chamber in­ traocular lenses. The difference between the group with the iris-supported lenses and the group with the anterior chamber lenses was not statistically significant (X2 = 0.83; P < .25). Only four of the 61 eyes (7%) had graft failures. All of these eyes had pseudopha­ kic bullous keratopathy. Two of the graft failures occurred in eyes with irissupported intraocular lenses and two oc­ curred in eyes with anterior chamber intraocular lenses. In three of these eyes the intraocular lenses were removed dur­ ing keratoplasty; in one eye an irissupported intraocular lens was left in place. One graft failure was attributed to bacterial keratitis, one occurred as a re­ sult of intractable rosacea keratopathy, and two were the result of severe immu­ nologie graft rejections. Reasons for postoperative visual acui­ ties worse than 20/40—We carefully ex­ amined the records of all 29 eyes (56%) with best corrected visual acuities worse than 20/40 one year after keratoplasty (Table 3). Visual loss was attributed to cystoid macular edema in 11 of these eyes, to severe glaucoma in 12, to senile

keratopathy and the eyes with pseudophakic bullous keratopathy (χ2 = 0.06; P < .5). Eleven of the 34 eyes (32%) with pseudophakic bullous keratopathy had cystoid macular edema after keratoplasty. Ten of the 11 (91%) had iris-supported intraocular lenses; in nine of these ten the cystoid macular edema first developed after keratoplasty. The 11th case was in an eye with an anterior chamber intraoc­ ular lens; this eye was first noted to have cystoid macular edema before keratoplas­ ty. Therefore, cystoid macular edema oc­ curred in ten of the 22 eyes (45%) with iris-supported intraocular lenses and one of the ten eyes (10%) with anterior cham­ ber intraocular lenses; this was not statis­ tically significant (\ 2 = 3.34; P < .05). Neither of the two eyes with posterior chamber intraocular lenses developed cystoid macular edema. Thirty-two of the 61 eyes (52%) were treated for glaucoma after keratoplasty. Twenty-two of these 32 eyes first devel­ oped glaucoma before keratoplasty. Of the 27 eyes with aphakic bullous keratop­ athy, 14 (52%) had postoperative glauco­ ma; five of these eyes had not had glauco­ ma before keratoplasty. There was no significant difference in the incidences of postoperative glaucoma between the group with aphakic bullous keratopathy and the group with pseudo­ phakic bullous keratopathy (χ2 = 0.034; P < .5). Of the 34 eyes with pseudopha­ kic bullous keratopathy, 18 (53%) had

TABLE 3 REASONS F O R VISUAL ACUITIES WORSE THAN 20/40 AFTER KERATOPLASTY

Aphakic Complication Cystoid macular edema Glaucoma Senile macular degeneration Graft failure

No.

%

6 6 2 0

22 22 7 0

Bullous Keratopathy Pseudophakic No. % 5 6 0 4

15 18 0 12

Total No.

%

11 12 2 4

18 20 3 7

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AMERICAN JOURNAL OF OPHTHALMOLOGY

macular degeneration in two, and to graft failure in four. Of the 11 eyes with cystoid macular edema, six had aphakic bullous keratopathy and five had pseudophakic bullous keratopathy. The 12 eyes with glaucoma severe enough to reduce visual acuity were equally divided between the group with aphakic bullous keratopathy and the group with pseudophakic bullous keratopathy. The two cases of senile mac­ ular degeneration were in eyes with aphakic bullous keratopathy and the four cases of graft failure were in eyes with pseudophakic bullous keratopathy. Effect of intraocular lens removal—We also examined the eyes with pseudopha­ kic bullous keratopathy with regard to the effects of intraocular lens removal (Table 4). The intraocular lenses were removed either during or before keratoplasty in 27 of the 34 eyes with pseudo­ phakic bullous keratopathy. Of the seven eyes with intraocular lenses left in place, four had anterior chamber intraocular lenses, two had iris-supported intraocular lenses, and one had a posterior chamber intraocular lens. The mean preoperative visual acuity of the 27 eyes with pseudo­ phakic bullous keratopathy in which the intraocular lenses were removed was be­ tween 20/400 and counting fingers; the mean visual acuity of these eyes after keratoplasty was 20/80. The mean preopTABLE 4 E F F E C T O F INTRAOCULAR LENS REMOVAL

IOL Status

Clinical Data No. of eyes Mean visual acuities Preoperative Postoperative Cystoid macular edema No.

Removed

In Place

27

7

20/40 to C F . 20/80

20/400 20/80

%

9 33

2 29

%

14 52

4 57

Glaucoma No.

SEPTEMBER, 1984

erative visual acuity of the seven eyes in which the intraocular lenses were left in place was 20/400; the mean visual acuity of this group after keratoplasty was 20/80. The incidences of postoperative compli­ cations were similar in the two groups. Of the 27 eyes in which the intraocular lens­ es were removed, nine (33%) had postop­ erative cystoid macular edema and 14 (52%) had postoperative glaucoma. Of the seven eyes with the lenses in place, post­ operative cystoid macular edema oc­ curred in two (29%) and postoperative glaucoma occurred in four (59%). Al­ though the difference in the incidences of cystoid macular edema was not significant (χ2 = 0.04; P < .5), the higher incidence of glaucoma in the eyes with the intraocu­ lar lenses in place was statistically signifi­ cant (χ2 = 6.07; P < .025). DISCUSSION

The results of this retrospective study correlated well with other recent reports of penetrating keratoplasty performed for aphakic bullous keratopathy and for pseudophakic bullous keratopathy (Table 5).2·3·13"20 Demographically, both the mean age (71.7 years) and predomi­ nance of females (68%) among our pa­ tients corresponded strikingly to previ­ ous studies.15"19 Further, in this study we also noted the disappointing discrepancy between anatomic and functional results. The rate of clear grafts for all patients in this study was 93%. Although the mean final visual acuity was between 20/50 and 20/60, there was a wide range of visual acuities. Twelve of 24 patients followed up for at least two years had visual acui­ ties of 20/40 or better, while ten had visual acuities of 20/200 or worse. The factors involved in the production of aphakic bullous keratopathy include surgical trauma, increased intraocular pressure, iridodonesis, persistent uveitis, iridocorneal synechiae, and vitreocorneal touch.2·21"25 Corneal decompensation after

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TABLE 5 SUMMARY O F CLINICAL DATA FROM RECENT STUDIES O F PENETRATING KERATOPLASTY

Study Waring and associates 16 Meunzler and Harms 2 Charlton, Binder, and Perl 15 Olson and associates 15 Waring and associates 16 Taylor and associates 3 Arentsen and Laibson Charlton, Binder, and Perl 15 Waltman 18 Meyer and Sugar17

Bullous Keratopathy

No. of Eves

Clear-Grafts

Aphakic Aphakic Aphakic Aphakic Pseudophakic Pseudophakic Pseudophakic Pseudophakic Pseudophakic Pseudophakic

88 73 31 21 35 31 36 19 24 25

81 78

cataract extraction is generally a slow process. Waring and associates 16 found that the mean time from cataract extrac­ tion to penetrating keratoplasty in their patients with aphakic bullous keratopathy was 67 months. In a similar report, Charl­ ton, Binder, and Perl 15 noted a mean corneal decompensation time of 80 months. In our study, the mean time from cataract extraction to penetrating keratoplasty in the 27 patients with apha­ kic bullous keratopathy was 82 months. Early experience with penetrating ker­ atoplasty performed for aphakic bullous keratopathy was uniformly poor; graft failures were usually attributed to iridocorneal adhesions or vitreocorneal touch.8"12 The marked improvement in the incidence of clear grafts reported in re­ cent studies213"16 is the result of several factors, including the widespread use of the operating microscope, monofilament sutures, improved surgical instrumenta­ tion, modern eye banking techniques, and the liberal use of postoperative corticosteroids. 8,13 · 14 The most significant ad­ vance, however, has been automated vitrectomy instrumentation 13 · 14 which has almost eliminated vitreocorneal touch after keratoplasty. 2,16 In our study, all the eyes with aphakic bullous keratopathy and intracapsular cataract extraction un­ derwent anterior vitrectomy, and the rate

(%)

— 95 91 88 94

— 94 88

Visual Acuity 20/40 (%)

34 34 26 15 16 32 33 16 54 52

of graft clarity was 100%. Polack,11 how­ ever, cautioned that longer follow-up pe­ riods would inevitably increase the inci­ dence of graft failure because of the continual slow loss of donor endothelial cells after keratoplasty. 26 Despite uniform graft clarity in our group with aphakic bullous keratopathy, 12 had best-corrected visual acuities worse than 20/40. These poor results were the result of postoperative cystoid macular edema or glaucoma. Cystoid macular edema occurred in eight of 27 eyes with aphakic bullous keratopathy. Olson and associates 13 reported a postop­ erative incidence of cystoid macular edema of 30% in their aphakic bullous keratopathy series; an incidence of 35% was noted by Charlton, Binder, and Perl. 10 As in the case of cataract extrac­ tions, 27 cystoid macular edema after apha­ kic penetrating keratoplasty has been at­ tributed to vitreous manipulation. 22 21 Kramer demonstrated a significantly greater incidence of postoperative cys­ toid macular edema in those eyes under­ going concurrent anterior vitrectoiny. In our study, two of the three eyes with aphakic bullous keratopathy that under­ went extracapsular extraction had intact posterior capsules and did not require anterior vitrectomy; neither of these eyes developed cystoid macular edema.

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We found that postoperative glaucoma occurred in 14 of 27 eyes with aphakic bullous keratopathy (52%). Most cases, however, were successfully controlled; increases in intraocular pressure account­ ed for visual field loss and visual acuity reduction in only six eyes. Other investi­ gators have also noted a high incidence of postoperative glaucoma in patients with aphakic bullous keratopathy. 214 · 20 Olson and associates 13 attributed postoperative glaucoma to surgically induced trabecular meshwork dysfunction. This increased in­ traocular pressure can result in signifi­ cant visual loss, even if it is ultimately controlled. 28 Pseudophakic bullous keratopathy is a relatively new disease entity. Perhaps 10% of pseudophakic eyes will have some degree of corneal decompensation. 3,17,29 " 31 Therefore, with the increasing popularity of intraocular lens implantations during the last decade, 5,7 pseudophakic bullous keratopathy has become the prime indi­ cation for penetrating keratoplasty. 1 The major factors contributing to corneal de­ compensation after cataract extraction with intraocular lens implantation in­ clude endothelial trauma during both the cataract extraction and intraocular lens implantation, increased intraocular pres­ sure, pseudophakodonesis, intraocular lens-cornea touch, and persistent iri­ tis.3,25,32"35 Arentsen and Laibson 19 report­ ed that as many as 50% of patients with pseudophakic bullous keratopathy may also have preexisting endothelial dystro­ phy. Thirty-four eyes in our study had pene­ trating keratoplasty for pseudophakic bullous keratopathy. Most eyes had irissupported intraocular lenses; this may reflect the greater incidence of complica­ tions associated with these lenses. 3,32 The mean time between cataract extraction and penetrating keratoplasty for the group with pseudophakic bullous kera­ topathy was 45.6 months; this was signifi­

SEPTEMBER, 1984

cantly less than that for the group with aphakic bullous keratopathy (P < .01). Waring and associates 16 also noted that corneal decompensation was significantly more rapid in pseudophakic bullous kera­ topathy than in aphakic bullous keratop­ athy. They attributed this to a greater degree of surgical trauma and postopera­ tive complications, particularly persistent iritis and pseudophakic corneal touch. Our graft clarity rate (88%) in pseudo­ phakic bullous keratopathy was in accord with several reported series of penetrat­ ing keratoplasty for pseudophakic bullous keratopathy.3,15"20 Our finding that 38% (eight of 22) of our eyes with pseudopha­ kic bullous keratopathy had final visual acuities of 20/40 or better was similar to those reported by Taylor and associates 3 and by Arentsen and Laibson, 19 but dif­ fered from the results of Waring and associates 16 and Charlton, Binder, and Perl. 15 In these series, only 16% attained visual acuities of 20/40 or better. Our visual acuity results, however, were worse than those reported by Meyer and Sugar17 and by Waltman. 18 As in eyes with aphakic bullous keratopathy, there was a wide range of visual acuities in the group with pseudophakic bullous keratopathy. We found no significant difference be­ tween the two groups at either one or two years after keratoplasty. Charlton, Binder, and Perl15 also found no differ­ ence between final visual results in apha­ kic bullous keratopathy and pseudopha­ kic bullous keratopathy. Our results, however, differed from those of Waring and associates 16 who noted significantly worse visual acuities in their eyes with pseudophakic bullous keratopathy than in their eyes with aphakic bullous keratop­ athy. In patients with pseudophakic bullous keratopathy, we found that cystoid macular edema and glaucoma were again the major reasons for poor visual acuity re­ sults. The incidence of cystoid macular

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edema after penetrating keratoplasty was 32%; this correlated well with findings in other reports.3·15"19 We found no differ­ ence between the group with aphakic bullous keratopathy and the group with pseudophakic bullous keratopathy. These results, while similar to those reported by Charlton, Binder, and Perl, 15 differed from those of Waring and associates 16 who noted a significantly greater incidence of cystoid macular edema in patients with pseudophakic bullous keratopathy. Fur­ ther, our results suggested that cystoid macular edema is more common in eyes with pseudophakic bullous keratopathy and iris-supported intraocular lenses, but this was not statistically significant. Fifty-three percent of our patients with pseudophakic bullous keratopathy had postoperative glaucoma. Other studies have documented a lesser incidence of glaucoma.15"19 Again, we found no signifi­ cant difference between the group with aphakic bullous keratopathy and the group with pseudophakic bullous kera­ topathy. Finally, we found that removal of the intraocular lens had no effect on visual acuity or incidence of complications. However, we used strict indications for intraocular lens removal. Charlton, Bind­ er, and Perl15 documented similar results. Arentsen and Laibson 19 reported better final visual acuities in those eyes in which the intraocular lenses were left in place. REFERENCES 1. Smith, R. E., McDonald, H. R. ; Nesbum, A. B., and Minckler, D. S.: Penetrating keratoplas­ ty. Changing indications, 1947 to 1978. Arch. Oph­ thalmol. 98:1226, 1980. 2. Muenzler, W. S., and Harms, W. K.: Visual prognosis in aphakic bullous keratopathy treated by penetrating keratoplasty. A retrospective study of 73 cases. Ophthalmic Surg. 12:210, 1981. 3. Taylor, D. M., Atlas, B. F., Romanchuck, K. G., and Stern, A. L.: Pseudophakic bullous kera­ topathy. Ophthalmology 90:19, 1983. 4. Nadler, D. J., and Schwartz, B.: Cataract sur­ gery in the United States, 1968-1976. A descriptive epidemiologic study. Ophthalmology 87:10, 1980.

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5. Stark, W. J., Leske, M. C , Worthen : D. M., and Murray, G. C : Trends in cataract surgery and intraocular lenses in the United States. Am. J. Oph­ thalmol. 96:304, 1983. 6. Sugar, J., Mitchelson, J., and Kraff, M.: Endothelial trauma and cell loss from intraocular lens insertion. Arch. Ophthalmol. 96:449, 1978. 7. Liesegang, T. J., Bourne, W. M., and Ilstrup, D. M.: Short- and long-term endothelial cell loss associated with cataract extraction and intraocular lens implantation. Am. J. Ophthalmol. 97:32, 1984. 8. Barraquer, J. : Keratoplasty in Fuchs' dystrophy and bullous keratopathy. Am. J. Ophthalmol. 88:333, 1979. 9. DeVoe, A. G.: Keratoplasty. Past, present and future. Arch. Ophthalmol. 66:652, 1961. 10. Thomas, J. W. T.: Considerations affecting technique and results in keratoplasty. Trans. Oph­ thalmol Soc. U.K. 75:473, 1955. 11. Castroviejo, R.: Indications and contraindica­ tions for keratoplasty and keratectomies. Am. J. Ophthalmol. 29:1081, 1946. 12. Franceschetti, A.: Corneal grafting. Trans. Ophthalmol. Soc. U.K. 69:17, 1949. 13. Olson, R. J., Waltman, S. R., Mattingly, T. P., and Kaufman, H. E. : Visual results after pene­ trating keratoplasty for aphakic bullous keratopathy and Fuchs' dystrophy. Am. J. Ophthalmol. 88:1000, 1979. 14. Polack, F. M.: Keratoplasty in aphakic eyes with corneal edema. Results in 100 cases with 10year follow-up. Trans. Am. Ophthalmol. Soc. 77:657, 1979. 15. Charlton, K. H., Binder, P. S., and Perl, T.: Visual prognosis in pseudophakic corneal trans­ plants. Ophthalmic Surg. 12:411, 1981. 16. Waring, G. O., Ill, Welch, S. N., Cavanagh, H. D., and Wilson, L. A.: Results of penetrating keratoplasty in 123 eyes with pseudophakic or apha­ kic corneal edema. Ophthalmology 90:25, 1983. 17. Meyer, R. F., and Sugar, A.: Penetrating ker­ atoplasty in pseudophakic bullous keratopathy. Am. J. Ophthlamol. 90:677, 1980. 18. Waltman, S. R.: Penetrating keratoplasty for pseudophakic bullous keratopathy. Visual results. Arch. Ophthalmol. 99:415, 1981. 19. Arentsen, J. J., and Laibson, P. R.: Surgical management of pseudophakic corneal edema. Com­ plications and visual results following penetrating keratoplasty. Ophthalmic Surg. 13:371, 1982. 20. Fine, M. : Keratoplasty for bullous keratopathy with intraocular lenses. Am. Intraocul. Implant Soc. J. 4:12, 1978. 21. Kramer, S. G.: Cystoid macular edema after aphakic penetrating keratoplasty. Ophthalmology 88:782, 1981. 22. West, C. E., Fitzgerald, C. R., and Sewell, J. H.: Cystoid macular edema following aphakic ker­ atoplasty. Am. J. Ophthalmol. 75:77, 1973. 23. Leibowitz, H. M., Laing, R. A., Chang, R., Theodore, J., and Oak, S. S.: Corneal edema secon­ dary to vitreocorneal contact. Arch. Ophthalmol. 99:417, 1981. 24. Nielsen, C. B.: Prostaglandin inhibition and

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central comeal thickness after cataract extraction. Acta Ophthalmol. 60:252, 1982. 25. Jacobi, K. W., and Jagger, W. S.: Physical forces involved in pseudophacodonesis and iridodonesis. Graefes Arch. Klin. Exp. Ophthalmol. 216:49, 1981. 26. Olsen, T.: Post-operative changes in the endothelial cell density of corneal grafts. Acta Ophthal­ mol. 59:863, 1981. 27. The Miami Study Group: Cystoid macular edema in aphakic and pseudophakic eyes. Am. J. Ophthalmol. 88:45, 1979. 28. Olson, R. J., and Kaufman, H. E.: Prognostic factors of intraocular pressure after aphakic keratoplasty. Am. J. Ophthalmol. 86:510, 1978. 29. Jaffe, N. S., and Duffner, L. R.: The iris-plane (Copeland) pseudophakos. Arch. Ophthalmol. 94:420, 1976. 30. Kaufer, G.: The results of 1000 intracapsular

SEPTEMBER,

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cataract extractions with the suture fixated Medallion lens implant. Ophthalmic Surg. 12:652, 1981. 31. Drews, R. C.: Inflammatory response, endophthalmitis, corneal dystrophy, glaucoma, retinal detachment, dislocation, refractive error, lens re­ moval and enucleation. Ophthalmology 85:164, 1978. 32. Rao, G. N., Stevens, R. E., Harris, J. K., and Aquavella, J. V.: Long-term changes in corneal endothelium following intraocular lens implantation. Ophthalmology 88:386, 1981. 33. Drews, R. C.: Intermittent touch syndrome. Arch. Ophthalmol. 100:1440, 1982. 34. Berkowitz, P., Orton, R. B., Boyaner, D., and Brownstein, S.: Pseudophakic bullous keratopathy: A clinico-pathologic analysis. Can. J. Ophthalmol. 14:3, 1979. 35. Polack, F. M.: Management of anterior seg­ ment complications of intraocular lenses. Ophthal­ mology 87:881, 1980.