Survival Outcome and Prognostic Factors of Corneal Transplantation: A 15-Year Retrospective Cohort Study at King Chulalongkorn Memorial Hospital

Figures & data

Table 1 Demographic Characteristics of the Study Population

Variables		N (704)	%
Patient characteristics
Sex
Male		393	55.82
Female		311	44.18
Recipient age (years), mean (SD)		54.37 (18.20)
< 21		30	4.26
21–40		139	19.74
41–60		240	34.09
61–80		270	38.35
> 81		25	3.55
Underlying disease
Diabetes		88	12.50
Hypertension		144	20.45
Blood dyscrasia		6	0.85
Cerebrovascular accident/ischemic heart disease		42	5.97
Dyslipidemia		67	9.52
Autoimmune; Thyroid, Rheumatoid arthritis, SLE		19	2.70
Occupation (n=468)
Employee		213	45.51
Unemployed		67	14.32
Business owner		42	8.97
Government officer		90	19.23
Student		30	6.41
Priest		26	5.56
Preoperative recipient status
Prior intraocular surgery		287	40.77
Corneal vascularization (n=693)
None		460	66.38
<50% NV		154	22.22
> 50% NV		79	11.40
Raised IOP/Glaucoma		142	20.17
Dry eye		29	4.12
Eyelid problem		31	4.40
Ocular surface disease		40	94.32
Lens status
Phakia		468	66.48
Pseudophakia		184	26.14
Aphakia		52	7.39
Waiting time to transplantation	Median (months, range)
Optical	3.83 (0, 16.2)	611	88.55
Therapeutic	0.24 (0, 3.6)	70	10.14
Tectonic	2.75 (0, 13.9)	9	1.30

Abbreviations: SLE, systemic lupus erythematosus; NV, neovascularization; IOP, intraocular ocular pressure.

Table 2 Indications and Primary Diagnosis of Corneal Transplantation

Indications and Primary Diagnosis	N	%
Indication of surgery
Optical	623	88.49
Therapeutic	72	10.23
Tectonic	9	1.28
Primary diagnosis
Pseudophakic/aphakic bullous keratopathy	111	15.77
Other corneal decompensation	44	6.68
Endothelial corneal dystrophy	42	5.97
Stromal corneal dystrophy	69	19.03
Other corneal dystrophy	18	2.56
Corneal scar/Opacity	178	25.28
Keratoconus	31	4.40
Active keratitis/ICK/IK	63	8.95
Perforation/Peripheral ulceration/Mooren’s ulcer	14	1.99
Regraft	104	14.77
OSD: Chemical/Thermal/SJS/LSCD/KCS	10	1.42
Others	17	2.41

Abbreviations: ICK, infectious crystalline keratopathy; IK, interstitial keratitis; OSD, ocular surface disease; SJS, Stevens-Johnson syndrome; LSCD, limbal stem cell deficiency; KCS, keratoconjunctivitis sicca.

Table 3 Types of Corneal Transplantation

Procedures	2000–2002		2003–2005		2006–2008		2009–2011		2012–2014
	N	%	N	%	N	%	N	%	N	%
PKP	50	56.18	81	59.12	84	53.50	93	57.06	82	51.90
Triple operation	25	28.09	33	24.09	34	21.66	24	14.72	34	21.52
PKP combined with other procedures	12	13.48	21	15.33	29	18.47	23	14.11	29	18.35
ALK	2	2.25	2	1.46	7	4.46	21	12.88	10	6.33
ALK combined with other procedure	0	0.00	0	0.00	0	0.00	1	0.61	1	0.63
EK	0	0.00	0	0.00	3	1.91	1	0.61	0	0.00
EK combined with cataract surgery	0	0.00	0	0.00	0	0.00	0	0.00	2	1.27

Abbreviations: PKP, penetrating keratoplasty; ALK, anterior lamellar keratoplasty; EK, endothelial keratoplasty.

Figure 1 The Kaplan-Meier survival curve analysis of overall corneal grafts.

Table 4 Survival Rates of Primary Diagnosis

Primary Diagnosis	n	1-Year Survival (%)	3-Year Survival (%)	5-Year Survival (%)	10-Year Survival (%)
PBK/ABK	111	90.99	68.04	40.6	31.79
Other corneal decompensation	47	85.11	70.99	42.33	31.75
Fuchs’ endothelial corneal dystrophy	42	85.71	77.51	68.63	68.63
Stromal corneal dystrophy	69	98.55	96.88	83.63	44
Other corneal dystrophy	18	100	86.57	86.57	–
Corneal scar/Opacity	178	92.7	79.27	73.52	57.77
Keratoconus	31	100	100	95.65	–
Active keratitis/ICK/IK	63	45.88	36.57	30.18	16.17
Perforation/Peripheral ulceration/Mooren’s ulcer	14	42.86	21.43	21.43	10.71
Regraft	104	80.77	54.39	39.24	25.11
OSD: Chemical/Thermal/SJS/LSCD/KCS	10	80	53.33	53.33	53.33
Others	17	88.24	88.24	41.36	–

Abbreviations: PBK, pseudophakic bullous keratopathy; ABK, aphakic bullous keratopathy; ICK, infectious crystalline keratopathy; IK, interstitial keratitis; OSD, ocular surface disease; SJS, Stevens-Johnson syndrome; LSCD, limbal stem cell deficiency; KCS, keratoconjunctivitis sicca.

Figure 2 The Kaplan–Meier graft survival rates for optical, therapeutic, and tectonic indications.

Table 5 Univariate Analysis of Graft Failure Association

Factors Associated with Graft Failure	Hazard Ratio	95% CI	p-value
Recipient age (years)
< 21	1.14	0.535, 2.42	0.739
21–40	1
41–60	1.93	1.36, 2.75	<0.001
61–80	1.83	1.29, 2.59	0.001
≥ 81	1.63	0.76, 3.47	0.206
Primary diagnosis
PBK/ABK	10.51	2.56, 43.18	0.001
Other corneal decompensation	10.32	2.43, 43.80	0.002
Fuchs’ endothelial corneal dystrophy	5.06	1.11, 23.10	0.036
Stromal corneal dystrophy	3.47	0.80, 15.08	0.098
Other corneal dystrophy	5.57	1.08, 28.73	0.040
Corneal scar/Opacity	4.83	1.17, 19.86	0.029
Keratoconus	1
Active keratitis/ICK/IK	27.14	6.57, 112.16	<0.001
Perforation/Peripheral ulceration/Mooren’s ulcer	29.62	6.55, 133.88	<0.001
Regraft	13.11	3.20, 53.68	<0.001
OSD: Chemical/Thermal/SJS/LSCD/KCS	8.18	1.50, 44.71	0.015
Others	8.74	1.76, 43.34	0.008
Pre-existing glaucoma/Raised IOP
No	1
Yes	1.86	1.42, 2.43	<0.001
Prior intraocular surgery
No	1
Yes	1.68	1.32, 2.12	<0.001
Lens status
Phakia	1
Pseudophakia	1.53	1.18, 1.98	0.001
Aphakia	1.29	0.84, 1.98	0.242
Indication of surgery
Optical	1
Therapeutic	4.26	3.13, 5.79	<0.001
Tectonic	6.22	3.06, 12.66	<0.001
Recipient graft size (mm)
< 7.0	2.14	1.13, 4.04	0.020
7.0–7.4	1.23	0.85, 1.79	0.269
7.5–7.9	1
8.0–8.4	1.94	1.13, 3.33	0.017
8.5–8.9	5.44	2.75, 10.75	<0.001
≥ 9.0	4.91	2.06, 11.69	<0.001
Donor endothelial cell count (cells/mm^2)	0.9991	0.9988, 0.9994	<0.001
Graft rejection
No	1
Yes	2.13	1.68, 2.70	<0.001

Abbreviations: PBK, pseudophakic bullous keratopathy; ABK, aphakic bullous keratopathy; ICK, infectious crystalline keratopathy; IK, interstitial keratitis; OSD, ocular surface disease; SJS, Stevens-Johnson syndrome; LSCD, limbal stem cell deficiency; KCS, keratoconjunctivitis sicca.

Table 6 Multivariate Analysis of Graft Failure Association

Factors Associated with Graft Failure	Hazard Ratio	95% CI	p-value
Primary diagnosis
PBK/ABK	7.97	1.93, 32.87	0.004*
Other corneal decompensation	7.81	1.83, 33.36	0.006*
Fuchs’ endothelial corneal dystrophy	5.21	1.14, 23.81	0.033*
Stromal corneal dystrophy	3.42	0.79, 14.90	0.101
Other corneal dystrophy	5.18	1.003, 26.69	0.050
Corneal scar/Opacity	4.24	1.03, 17.45	0.045*
Keratoconus	1
Active keratitis/ICK/IK	24.30	5.88, 100.43	<0.001^†
Perforation/Peripheral ulceration/Mooren’s ulcer	28.57	6.32, 129.16	<0.001^†
Regraft	9.37	2.27, 38.66	0.002*
OSD: Chemical/Thermal/SJS/LSCD/KCS	7.40	1.353, 40.47	0.021*
Others	6.88	1.38, 34.28	0.019*
Pre-existing glaucoma/Raised IOP
No	1
Yes	1.52	1.13, 2.04	0.006*
Graft rejection
No	1
Yes	1.95	1.54, 2.48	<0.001^†

Notes: *p <0.05. ^†p <0.001.

Abbreviations: PBK, pseudophakic bullous keratopathy; ABK, aphakic bullous keratopathy; ICK, infectious crystalline keratopathy; IK, interstitial keratitis; OSD, ocular surface disease; SJS, Stevens-Johnson syndrome; LSCD, limbal stem cell deficiency; KCS, keratoconjunctivitis sicca.