Traditional Glaucoma Surgery Significantly Increases Endothelial Keratoplasty Risk

A worrying 10% of glaucoma patients or suspects who underwent tube shunt surgeries experienced corneal endothelial decompensation necessitating corneal endothelial transplantation. This risk was halved in patients treated with trabeculectomy but still significantly greater than the risk seen in those who received MIGS or laser trabeculoplasty. Photo: Justin Schweitzer, OD. Click image to enlarge. It has been documented that glaucoma and its treatments—surgeries in particular—can reduce endothelial cell density, raising the risk of corneal decompensation. A recent study used data from the IRIS Registry to evaluate the real-world incidence of corneal endothelial transplantation (CET) in a large population of patients with glaucoma or suspected glaucoma, particularly examining the impact of various glaucoma treatment modalities. The researchers reported that traditional interventions, including tube shunt surgery or trabeculectomy, significantly elevated the risk of endothelial keratoplasty, while minimally invasive glaucoma surgery (MIGS) and laser trabeculoplasty did not increase CET; in fact, the data suggested that the latter interventions may even exert a protective effect on corneal endothelial health.The observational cohort study, published earlier this week in Ophthalmology Glaucoma, involved 7,827,337 individuals from the IRIS Registry who were diagnosed with glaucoma or categorized as glaucoma suspects. Participants with pre-existing corneal diseases or those who had experienced penetrating trauma were excluded from the analysis. By the end of the follow-up period (2013 to 2023), a total of 615,907 patients had undergone glaucoma surgery, with 8,141 cases progressing to require CET. Notably, for those who had tube shunt surgery, the risk of requiring CET was significantly higher at 10% compared to 2.5% for those who had a trabeculectomy.The adjusted hazard ratios (aHR) highlighted a pronounced risk associated with these traditional surgical methods; tube shunt surgery was linked to an aHR of 6.63, while trabeculectomy presented an aHR of 3.06. Chronic use of IOP-lowering drops also conferred a modestly increased risk (aHR: 1.15). On the other hand, MIGS and laser trabeculoplasty appeared to protect against CET, with aHRs of 0.80 and 0.70, respectively.In the discussion portion of their paper, the researchers explained, “The clinically important increased risk of corneal endothelial decompensation following tubes/shunts should be considered carefully in deciding whether tube/shunt surgery is the optimal approach for managing IOP elevation.” This consideration is especially warranted when managing uveitic eyes, they added, as a separate large cohort study found that uveitis is a strong risk factor for endothelial keratoplasty (9% incidence by five years).Using IRIS registry data, the researchers note that they were “unable to parse out the impact of specific trabeculectomy and tube/shunt techniques on outcomes.” They suggest that future studies evaluate the impact of specific surgical strategies on postoperative corneal endothelial decompensation, commenting that, “It would be helpful to know if the use of mitomycin C or 5-fluorouracil with trabeculectomy or if alternative implantation locations of tubes/shunts are associated with altered risk.”In conclusion, the authors noted, “These findings underscore the importance of selecting glaucoma treatments that optimize IOP control while preserving corneal endothelial integrity.”Click here for the journal source. Bal SB, Ivanov A, Kearney W, et al. Corneal endothelial keratoplasty following glaucoma treatment: an American Academy of Ophthalmology IRIS Registry analysis. Ophthalmol Glaucoma. February 24, 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.