Corneal Transplantation for Infectious Keratitis: A Prospective Dutch Registry Study

Abstract

Purpose: The aim of this study was to analyze real-world practice patterns and graft survival after corneal transplantation for infectious keratitis in the Netherlands.

Methods: All consecutive keratoplasties for infectious keratitis registered in the Netherlands Organ Transplant Registry were included. Graft survival was analyzed using Kaplan-Meier survival curves with Cox regression to compare the 3 most common pathogens with subgroup analysis for type and reason of transplantation, sex, and graft size. Multivariable analysis was performed using the same explanatory factors.

Results: Between 2007 and 2017, 1111 keratoplasties for infectious keratitis were registered in the Netherlands Organ Transplant Registry. The most common pathogens were viruses (n = 437), bacteria (n = 271), and Acanthamoeba (n = 121). Human leukocyte antigen (HLA) matching did not provide a significant survival benefit, whereas emergency procedures showed worse graft survival [hazard ratio (HR) = 0.40, P = 0.120; HR = 2.73, P < 0.001, respectively]. Graft size >8.5 mm was significantly worse than graft size 8.5 mm (HR = 2.062, P = 0.010). In therapeutic keratoplasty, graft survival was significantly worse for Acanthamoeba than viral keratitis (HR = 2.36, P = 0.008). In the multivariable model, adjusting for graft size, type, and reason for transplantation, viral and bacterial keratitis did not differ significantly in graft survival, and Acanthamoeba showed a significantly worse prognosis (vs. viral keratitis, HR = 2.30, P < 0.001; bacterial keratitis, HR = 2.65, P < 0.001).

Conclusions: Viral keratitis was the most common indication for transplantation, followed by bacterial and Acanthamoeba keratitis. HLA matching did not offer protection over elective non-HLA-matched procedures, whereas emergency procedures and grafts sized >8.5 mm showed poor survival. In optical keratoplasty, survival is high for all pathogens, whereas in therapeutic keratoplasty Acanthamoeba shows poor outcome.

FIGURE 1.

A, Volume of all corneal transplantation (green) compared with corneal transplantation for infectious keratitis (blue) in the Netherlands from 2007 until 2017. The overall volume of corneal transplantation increased over time but remained stable for infectious keratitis. B, Number of transplantation for infectious keratitis per pathogen per year. The number of grafts for Acanthamoeba keratitis increased significantly in the second half of the cohort.

FIGURE 2.

A, Graft survival of primary corneal transplantation and retransplantation for infectious keratitis in the Netherlands. B, Five-year graft survival did not differ between viral and bacterial keratitis but was significantly worse in Acanthamoeba keratitis. C, Emergency procedures showed significantly worse graft survival, whereas human leukocyte antigen (HLA) did not provide significant survival benefit compared with elective non-HLA–matched procedures. D, Graft survival of optical and therapeutic keratoplasty in infectious keratitis. In 49 cases, the reason for transplantation was unknown or unclassifiable. HLA = human leukocyte antigen. E, Graft survival did not differ between donor–recipient sex-matched and sex-mismatched cases. F, Five-year graft survival of grafts sized >8.5 mm was significantly worse compared with grafts sized 8.5 mm, whereas grafts sized <8.5 mm did not differ statistically from grafts sized 8.5 mm. In 44 cases, the graft size was unknown.

FIGURE 3.

A, In emergency procedures, Acanthamoeba keratitis showed significantly worse graft survival compared with viral and bacterial keratitis. B, In elective non-human leukocyte antigen (HLA)-matched procedures, Acanthamoeba keratitis showed significantly worse graft survival compared with viral and bacterial keratitis. C, In optical keratoplasty, 2-year graft survival did not differ significantly between pathogens. D, In therapeutic keratoplasty, 2-year graft survival was comparable between viral and bacterial keratitis and significantly worse for Acanthamoeba keratitis. HLA = human leukocyte antigen.