Corneal Endothelial Keratoplasty Following Glaucoma Treatment: An American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) Analysis.

PURPOSE

To evaluate the impact of various glaucoma treatments on the incidence of corneal endothelial decompensation requiring corneal endothelial transplantation (CET) and to identify predictive factors for CET in patients with glaucoma or glaucoma suspect status.

DESIGN

Retrospective registry-based cohort study using the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

PARTICIPANTS

Adults diagnosed with glaucoma or glaucoma suspect status with or without intraocular pressure (IOP)-lowering interventions. Individuals with pre-existing corneal pathology or penetrating trauma were excluded.

METHODS

Demographic and clinic data were extracted for each participant-eye from January 1, 2013, to April 14, 2023, using ICD-9-CM/ICD-10-CM and CPT codes. The eligible cohort was followed forward in time for endothelial keratoplasty incidence. Survival analysis and multivariate Cox proportional hazards regression models were employed to estimate CET incidence and assess predictive factors for CET, defined as partial-thickness lamellar transplantation due to endothelial decompensation.

MAIN OUTCOME MEASURE

Incidence of CET used as an indicator of corneal endothelial decompensation.

RESULTS

Among 7,827,337 eligible participants (42% men), glaucoma surgery was documented in 615,907 individuals. Overall, 8,141 patients (0.13%) underwent CET (incidence rate: 0.03% per person-year). Within the subset undergoing glaucoma surgery, 27,513 (0.4%) had trabeculectomy, and 42,835 (0.5%) had tube or shunt surgery as their initial intervention. Compared to untreated eyes, the risk of subsequent CET was significantly increased following tube/shunt surgery (adjusted hazard ratio [aHR]: 6.63; 95%

CI

5.93-7.41), trabeculectomy (aHR: 3.06; 95%

CI

2.62-3.59), and IOP-lowering drops (aHR: 1.15; 95%

CI

1.06-1.24). Conversely, minimally invasive glaucoma surgery (aHR: 0.80; 95%

CI

0.68-0.95) and laser trabeculoplasty (aHR: 0.70; 95%

CI

0.63-0.78) were associated with significantly decreased CET risk.

CONCLUSIONS

This large study highlights the substantially elevated risk of endothelial keratoplasty following traditional glaucoma surgeries such as tube/shunt implantation and trabeculectomy as well as the modestly increased risk associated with chronic topical glaucoma therapy. Conversely, minimally invasive glaucoma surgery and laser trabeculoplasty were associated with no increase in CET, and possibly even a protective effect on corneal endothelial health. These findings underscore the importance of selecting glaucoma treatments that optimize IOP control while preserving corneal endothelial integrity.