Preexisting and postoperative glaucoma in repeated corneal transplantation

To evaluate the incidence, risk factors, management, and visual outcome of postoperative glaucoma in comparison with preexisting glaucoma in repeated corneal transplantation.

The charts of all the patients who underwent repeated corneal transplantation between 1985 and 1998 were reviewed for the occurrence of preexisting and postoperative glaucoma. Eighty patients underwent 122 repeated corneal transplantations, of which six underwent surgery in both eyes. The mean follow-up period from the primary keratoplasty was 89.5 months and the minimal follow-up period was at least 6 months after the last transplantation.

Postoperative glaucoma affected 29 eyes (34%) in 28 patients (35%) with repeated corneal transplantation. Herpetic scar as an indication for transplantation and a history of previous immune graft rejection were more common in patients who developed postoperative glaucoma compared with the entire regrafted group ( p= 0.016 and p< 0.001, respectively). The incidence of glaucoma usually increased with the increased number of keratoplasties. The following types of glaucoma were disclosed: closed angle (59%), corticosteroid induced (21%), open angle (11%), angle recession (3%), aqueous misdirection (3%), and unknown cause (3%). Surgical intervention was required in 62%. Glaucoma was controlled in nine eyes (31%) and resolved following regrafting or discontinuation of corticosteroids in four eyes (14%), of which five (17%) had clear regrafts. Better intraocular pressure control was achieved in those cases that did not require surgical intervention ( p= 0.019). In 15 eyes (52%), regrafts failed due to uncontrolled glaucoma and/or other causes. At the end of the follow-up period, visual acuity was 20/30 to 20/200 in 17%, counting fingers from less than 20 ft in 31%, hand movement/light perception in 35%, and no light perception in 17%. Six of the 86 eyes (7%) in six patients (7.5%) had preexisting glaucoma. Graft clarity and glaucoma control in patients with preexisting glaucoma were similar to those of postkeratoplasty glaucoma (50% had controlled glaucoma and 33% had clear regraft).

Glaucoma, either preexisting or postoperative, is one of the most devastating complications of repeated corneal transplantation and the cause for regraft failure and visual loss even when intensively treated. Close monitoring and early targeted therapy are warranted to increase the survival of repeated corneal transplants in eyes affected by glaucoma.