Trends in PK Use Show Shift to Lamellar Techniques for Simpler Cases

Patients undergoing PK for trauma/perforation or corneal edema experienced worse outcomes, while those with corneal ectasia had the most favorable results. A similar pattern was observed for visual acuity outcomes. Photo: Mitch Ibach, OD. Click image to enlarge. As lamellar corneal transplant procedures have emerged as generally safer alternatives to penetrating keratoplasty (PK), use of full-thickness grafts has declined. To investigate these trends, Johns Hopkins researchers recently evaluated the records of 4,061 new PK patients in the IRIS Registry from October 2015 to December 2017. Corneal graft survival, transplant-specific outcomes and postoperative complications were evaluated. Best-corrected visual acuity (BCVA) was assessed at one year and five years, graft survival and BCVA were stratified based on reported presumed surgical indication and risk factors for corneal graft failure were evaluated using multivariate analysis. The findings were reported in Ophthalmology.A consistent trend across graft survival, visual acuity outcomes and complications was observed based on surgical indication: patients undergoing PK for trauma/perforation or corneal edema experienced worse outcomes, while those with corneal ectasia had the most favorable results. Among groups with sufficient sample size (>10 eyes), the highest five-year graft failure probability was seen in the trauma/perforation cohort (31.4%), followed by corneal edema (23.2%), and lowest in corneal ectasia (8.5%).A similar pattern was observed for visual acuity outcomes: At five years, the probability of eyes having BCVA of 20/70 or worse was highest for corneal edema (91.3%) and corneal opacities (90.9%), while lowest for corneal ectasia (67.2%).Complication rates at five years were also greatest in the trauma/perforation (85.1%) and corneal opacities (57.1%) groups, compared to corneal ectasia (39.5%), although not all patients had follow-up duration for five years.“Our findings align with earlier studies showing superior graft survival in patients undergoing PK for corneal ectasia,” the authors wrote in their paper. “Furthermore, our study also demonstrates that these patients have favorable outcomes with respect to postoperative complications and visual acuity, which few studies in recent literature have evaluated. However, our results suggest worse outcomes for corneal ectasia patients compared to older studies from 2000 to 2006.”For instance, while the five-year graft failure probability for corneal ectasia was 8.5%, earlier studies with comparable follow-up durations (2.8 to five years) reported lower failure rates of 0% to 3%, and one 13.8-year follow-up study reported 6.3% failure. Similarly, in this study, only 22.8% of ectasia eyes had the probability of BCVA 20/70 vision or better at five years, whereas earlier reports indicated 73.2% to 86.% of patients achieved 20/40 or better. The graft failure probability for the entire cohort at five years in this study was 18.9%, whereas a prior study examining data from 1982 to 1988 indicated the failure rate to be 10%.“These discrepancies likely reflect a shift in the patient population: corneal ectasias—associated with the most favorable outcomes for PK—now account for a smaller proportion of PKs likely due to improved medical management and surgical intervention to prevent progression and those who require PK may represent more advanced or high-risk cases than those treated in earlier eras,” the authors explained in their paper. While many earlier studies have listed keratoconus/corneal ectasia as the leading indication for PK (ranging from 16% to 26%), the proportion reported in this cohort is in the lower range at 17.7%.The findings suggest a shift in the indications for PK, with fewer procedures being performed for lower-risk indications such as corneal ectasia and Fuchs’ dystrophy and instead used for more severe or complex cases.“Despite advances in surgical techniques, medical management and graft preservation by eye banks, outcomes for PK remain poor for many of these higher-risk indications,” the authors wrote in their paper. “Irrespective of surgical indication, long-term VA remained poor at five years, with the majority of patients having probability of VA 20/70 or worse (76% to 86% across the entire cohort). Furthermore, the postoperative period was also marked by a high burden of ocular complications, with 43.4% of patients experiencing at least one complication during follow-up.”Click here for the journal source. Cui D, Srikumaran D, Li C, et al. Current indications and outcomes of penetrating keratoplasty in the United States: an IRIS Registry (Intelligent Research in Sight) Study. Ophthalmol. January 23, 2026. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.