Publications by authors named "Mark N A Jones"

19 Publications

  • Page 1 of 1

Corneal Transplant Follow-up Study II: a randomised trial to determine whether HLA class II matching reduces the risk of allograft rejection in penetrating keratoplasty.

Br J Ophthalmol 2020 Dec 2. Epub 2020 Dec 2.

Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.

Purpose: A randomised trial to test the hypothesis that human leucocyte antigen (HLA) class II matching reduces the risk of allograft rejection in high-risk penetrating keratoplasty (PK).

Methods: All transplants were matched for HLA class I antigens (≤2 mismatches at the A and B loci) and corneas were allocated to patients by cohort minimisation to achieve 0, 1 or 2 HLA class II antigen mismatches. The corneal transplants (n=1133) were followed for 5 years. The primary outcome measure was time to first rejection episode.

Results: Cox regression analysis found no influence of HLA class II mismatching on risk of immunological rejection (HR 1.13; 95% CI 0.79 to 1.63; p=0.51). The risk of rejection in recipients older than 60 years was halved compared with recipients ≤40 years (HR 0.51; 95% CI 0.36 to 0.73; p=0.0003). Rejection was also more likely where cataract surgery had been performed after PK (HR 3.68; 95% CI 1.95 to 6.93; p<0.0001). In univariate analyses, preoperative factors including chronic glaucoma (p=0.02), vascularisation (p=0.01), inflammation (p=0.03), ocular surface disease (p=0.0007) and regrafts (p<0.001) all increased the risk of rejection. In the Cox model, however, none of these factors was individually significant but rejection was more likely where≥2 preoperative risk factors were present (HR 2.11; 95% CI 1.26 to 3.47; p<0.003).

Conclusions: HLA class II matching, against a background of HLA class I matching, did not reduce the risk of allograft rejection. Younger recipient age, the presence of ≥2 preoperative risk factors and cataract surgery after PK all markedly increased the risk of allograft rejection.

Trial Registration Number: ISRCTN25094892.
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http://dx.doi.org/10.1136/bjophthalmol-2020-317543DOI Listing
December 2020

Differential Survival of Penetrating and Lamellar Transplants in Management of Failed Corneal Grafts.

JAMA Ophthalmol 2018 08;136(8):859-865

UCL Institute of Ophthalmology, University College London, London, England.

Importance: An increasing proportion of corneal transplant procedures are undertaken for replacement of a failed previous graft. The proportion of lamellar transplant procedures has significantly increased. There are limited large-scale reports on regraft procedures that may help guide surgeons and patients in their choice of surgery.

Objective: To examine the corneal transplant replacement survival rates for the 3 main indications and types of regraft surgery.

Design, Setting, And Participants: This national transplant registry study examined surgery and follow-up data on all corneal transplants performed in the United Kingdom from April 1, 1999, through March 31, 2016.

Main Outcomes And Measures: Actuarial regraft 5-year survival rates were compared for the 3 main indications and types of graft: penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty for keratoconus, PK and endothelial keratoplasty (EK) for Fuchs endothelial dystrophy (FED), and pseudophakic bullous keratopathy (PBK).

Results: A total of 9925 regrafts were analyzed during the 17-year study period. Penetrating keratoplasty represented 7261 cases (73.2%) in the cohort. Endothelial keratoplasty increased by 1361.5%, from 12 (2.6%; 95% CI, 1.3%-4.5%) of all 467 regrafts during 2005-2006 to 292 (38.0%; 95% CI, 34.6%-41.6%) of 768 during 2015-2016. The median time to first regraft for all graft types was 28 months (interquartile range, 10-64 months). When examining all graft types performed for all indications, stratification of 5-year survival was found for successive grafts, with a difference in survival of 25 270 (72.5%; 95% CI, 71.7%-73.2%) from the first graft to 4224 (53.4%; 95% CI, 51.4%-55.4%) from the second graft and 1088 (37.3%; 95% CI, 33.4%-41.3%) from the second to third graft. For first regrafts in keratoconus and PBK, survival after lamellar and PK procedures was similar. For FED, there was a higher regraft survival after PK (375 [70.8%]; 95% CI, 64.6%-76.1%) compared with EK (303 [54.7%]; 95% CI, 45.8%-62.8%) (P < .001). For FED and PBK, there was no difference in first regraft survival identified between EK followed by PK vs PK followed by PK or EK followed by EK vs PK followed by EK.

Conclusions And Relevance: In this large registry-based analysis of corneal regraft survival, regraft survival was found to vary with indication for first graft surgery and for FED with type of regraft procedure performed. For FED and PBK, the permutation of graft and subsequent first regraft procedure were not associated with any survival benefit for the first regraft. These reported outcomes may assist decision-making in management of a failed corneal transplant.
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http://dx.doi.org/10.1001/jamaophthalmol.2018.1515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142952PMC
August 2018

Corneal transplant follow-up study II (CTFS II): a prospective clinical trial to determine the influence of HLA class II matching on corneal transplant rejection: baseline donor and recipient characteristics.

Br J Ophthalmol 2019 01 22;103(1):132-136. Epub 2018 Mar 22.

Bristol Medical School, University of Bristol, Bristol, UK.

Purpose: To describe a study to determine the influence of HLA class II matching on allograft rejection of high-risk, full-thickness corneal transplants.

Methods: A prospective, longitudinal, clinical trial (ISRCTN25094892) with a primary outcome measure of time to first clinically determined rejection episode. Tissue typing used DNA-based techniques. Corneas were allocated to patients with ≤2 human leucocyte antigen (HLA) class I antigen mismatches by cohort minimisation to achieve 0, 1 or 2 HLA class II (HLA-DR) antigen mismatches. Transplants were to be followed up at 6 months and then annually on the anniversary of surgery for 5 years. Power calculations estimated a sample size of 856 transplants to detect a 0.1 difference in probability of rejection at 1 year between HLA class II matched and mismatched transplants at the 5% level of significance with 80% power.

Results: To allow for loss to follow-up, 1133 transplants in 980 patients were accrued to the study between 3 September 1998 and 2 June 2011. 17% of transplants had 0 HLA-DR mismatches. The most frequent indication was bullous keratopathy, accounting for 27% of transplants and 54% of the transplants were regrafts. Median waiting time for a matched graft was 3 months. Donor and recipient characteristics were distributed evenly across the study groups.

Conclusion: Recruitment to the CFS II has closed with 1077/1133 transplants meeting all the study criteria. Follow-up has been completed and final analysis of the data has started.

Trial Registration Number: ISRCTN25094892 andUKCRNID9871, Pre-results.
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http://dx.doi.org/10.1136/bjophthalmol-2017-311342DOI Listing
January 2019

Influence of Socioeconomic Deprivation on Visual Acuity in Patients Undergoing Corneal Transplantation.

Cornea 2018 Jan;37(1):28-32

Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom.

Purpose: To determine whether there is an association between socioeconomic status and best-corrected visual acuity (BCVA) in patients undergoing corneal transplantation in the United Kingdom.

Methods: Retrospective cohort study of 4306 patients registered on the national United Kingdom Transplant Registry and undergoing penetrating keratoplasty, anterior lamellar keratoplasty, or endothelial keratoplasty in 2002, 2008, and 2013. Socioeconomic status was determined by applying a validated deprivation index to generate a score based on 5 categories. Patients' demographic details, preoperative BCVA, copathology, surgical center volume, and socioeconomic status were analyzed for univariate effects of categorical and continuous variables. Binary logistic regression was used to determine whether preoperative BCVA was affected by socioeconomic status after adjusting for other factors.

Results: A larger percentage of the most deprived group was female in each period compared with the least deprived, but this was only significant in 2002 (48.7% vs. 40.3%; P = 0.04). There was no interaction between socioeconomic status and the preoperative BCVA in the grafted eye. However, BCVA in the fellow eye was poorer for the most economically deprived patients compared with the least deprived in 2013 (P = 0.01).

Conclusions: We found no evidence of a relationship between socioeconomic deprivation and BCVA in the transplant recipient eye. However, there was clear evidence of an association between socioeconomic deprivation and reduced acuity in fellow eyes, for which barriers to access or low patient demand may be possible contributors.
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http://dx.doi.org/10.1097/ICO.0000000000001406DOI Listing
January 2018

Reply: To PMID 25089353.

Am J Ophthalmol 2015 Aug;160(2):393-4

Liverpool, United Kingdom.

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http://dx.doi.org/10.1016/j.ajo.2015.04.035DOI Listing
August 2015

Corneal transplant surgery for keratoconus and the effect of surgeon experience on deep anterior lamellar keratoplasty outcomes.

Am J Ophthalmol 2014 Dec 28;158(6):1239-46. Epub 2014 Aug 28.

St Paul's Eye Unit, 8X Link, Royal Liverpool University Hospital, Liverpool, United Kingdom. Electronic address:

Purpose: To investigate graft survival and surgical experience on clinical outcome following deep anterior lamellar keratoplasty (DALK).

Design: Multicenter cohort study.

Methods: The United Kingdom Transplant Database was used to identify patients who had undergone a first DALK or penetrating keratoplasty (PKP) for keratoconus. Data were collected at the time of surgery and at 1, 2, and 5 years postoperatively. Graft survival, best-corrected visual acuity, and refractive error were analyzed for 3 consecutive time periods. DALK outcomes were analyzed according to surgeon experience.

Results: A total of 4521 patients were included. Graft survival was 92% (95% CI: 90-92) for PKP and 90% (95% CI: 88-92) for DALK (P = .09). For corneal transplants undertaken in the periods 1999-2002, 2002-2005, and 2005-2007, graft survival was 90%, 92%, and 88% following DALK, and 93%, 91%, and 92% following PKP, respectively. There was no evidence of a difference between surgeons in terms of case mix (P = .4) or outcome (P = .2). Surgeon experience, in terms of the number of previous DALK undertaken, had no significant effect on outcome. A donor recipient trephine size disparity of 0.5 mm was associated with an increased risk of graft failure for both DALK (P = .03) and PKP (P = .002), whereas ocular surface disease was a significant risk factor for DALK (P = .04) but not PKP.

Conclusions: There has been little change in graft survival for DALK and PKP over the past decade. Ocular surface disease is an important risk factor for graft failure following DALK. A surgical learning curve for DALK could not be demonstrated in terms of clinical outcome.
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http://dx.doi.org/10.1016/j.ajo.2014.08.029DOI Listing
December 2014

Center and surgeon effect on outcomes of endothelial keratoplasty versus penetrating keratoplasty in the United Kingdom.

Am J Ophthalmol 2014 Nov 1;158(5):957-66. Epub 2014 Aug 1.

Moorfields Eye Hospital, London, United Kingdom. Electronic address:

Purpose: To compare national outcomes of endothelial keratoplasty (EK) and penetrating keratoplasty (PK) during comparable 6-year periods.

Design: Prospective cohort study of national registry data.

Methods:

Setting: United Kingdom National Transplant Registry, 2000 through 2011, inclusive.

Patient Population: All United Kingdom patients undergoing first EK (n = 2074) for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy from January 2006 through December 2011. Comparison cohort of patients undergoing first PK (n = 2622, same indications, January 2000 through December 2005).

Observation Procedure: Year of surgery, surgeon and center experience, corneal diagnosis, donor factors, patient factors, and surgical risk factors were analyzed against graft survival and visual outcomes.

Results: For both Fuchs endothelial dystrophy and pseudophakic bullous keratopathy, EK achieved better average best-corrected acuity and lower refractive error. For both groups, graft failure was significantly higher for EK than PK. EK failure in Fuchs endothelial dystrophy was associated with center experience (hazard ratio [HR], 2.3; P < .0001), donor endothelial density (HR, 1.8; P = .01), glaucoma at time of surgery (HR, 2.1; P = .003), and donor age older than 75 years (HR, 1.3; P = .05). EK failure in pseudophakic bullous keratopathy was associated with center experience of fewer than 15 cases (HR, 2.0; P < .0001) and glaucoma at time of surgery (HR, 1.7; P = .002).

Conclusions: Prospective national registry data for EK showed higher graft failure than is seen in PK or in retrospective case series of EK. Higher failure rates may be acceptable given established benefits of the procedure, including lower refractive error, structural globe integrity, and faster visual recovery. Center experience influenced EK survival more than surgeon experience, and overall surgical outcomes may be improved by standardized techniques and support within experienced units.
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http://dx.doi.org/10.1016/j.ajo.2014.07.037DOI Listing
November 2014

The suitability of corneas stored by organ culture for penetrating keratoplasty and influence of donor and recipient factors on 5-year graft survival.

Invest Ophthalmol Vis Sci 2014 Feb 10;55(2):784-91. Epub 2014 Feb 10.

Corneal Transplant Service Bristol Eye Bank, Bristol, United Kingdom.

Purpose: To determine the impact of donor factors on the suitability of corneas stored by organ culture for penetrating keratoplasty (PK) and the influence of donor and recipient factors on 5-year survival of first PK.

Methods: Logistic regression analyses were carried out to determine the influence of donor factors on, respectively, the risk of microbial contamination during organ culture, the suitability of corneas for PK (endothelial cell density ≥ 2200 cells/mm(2)), and the quality of corneas (endothelial cell density ≥ 2500 cells/mm(2)). Only one cornea, randomly selected, from each donor was included in these analyses. A Cox regression analysis was used to determine the influence of donor and recipient factors on 5-year PK survival.

Results: Risk of contamination (n = 8317): Causes of donor death including infection, respiratory disease, and cancer all increased the risk of contamination during organ culture (P < 0.0001). Suitability for PK and endothelial quality (n = 7107): Donor age (P < 0.0001) and storage time in organ culture (P < 0.0001) were the principal factors affecting suitability and quality. Death to enucleation and enucleation to processing times had little influence. Corneas from organ donors were more likely to be suitable for PK (P = 0.0003). Five-year graft survival (n = 3014): Graft survival was dominated by the indication for PK (P < 0.0001). Allograft rejection was also a major risk factor for failure (P < 0.0001). The only donor factor affecting survival was sex (P = 0.008).

Conclusions: Donor age and storage time but not postmortem times influenced the suitability of corneas for PK. The indication for PK and other recipient factors were the main predictors of graft failure.
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http://dx.doi.org/10.1167/iovs.13-13386DOI Listing
February 2014

The effect of socioeconomic deprivation on corneal graft survival in the United Kingdom.

Ophthalmology 2013 Dec 16;120(12):2436-2441. Epub 2013 Oct 16.

St. Paul's Eye Unit, Royal Liverpool Hospital, Liverpool, United Kingdom.

Objective: To investigate the effect of socioeconomic deprivation on cornea graft survival in the United Kingdom.

Design: Retrospective cohort study.

Participants: All the recipients (n = 13,644) undergoing their first penetrating keratoplasty (PK) registered on the United Kingdom Transplant Registry between April 1999 and March 2011 were included.

Methods: Data of patients' demographic details, indications, graft size, corneal vascularization, surgical complication, rejection episodes, and postoperative medication were collected at the time of surgery and 1, 2, and 5 years postoperatively. Patients with endophthalmitis were excluded from the study. Patients' home postcodes were used to determine the socioeconomic status using a well-validated deprivation index in the United Kingdom: A Classification of Residential Neighborhoods (ACORN). Kaplan-Meier survival and Cox proportional hazards regression were used to evaluate the influence of ACORN categories on 5-year graft survival, and the Bonferroni method was used to adjust for multiple comparisons.

Main Outcome Measures: Patients' socioeconomic deprivation status and corneal graft failure.

Results: A total of 13,644 patients received their first PK during the study periods. A total of 1685 patients (13.36%) were lost to follow-up, leaving 11,821 patients (86.64%) for analysis. A total of 138 of the 11,821 patients (1.17%) developed endophthalmitis. The risk of graft failure within 5 years for the patients classified as hard-pressed was 1.3 times that of the least deprived (hazard ratio, 1.3; 95% confidence interval, 1.1-1.5; P = 0.003) after adjusting for confounding factors and indications. There were no statistically significant differences between the causes of graft failure and the level of deprivation (P = 0.14).

Conclusions: Patients classified as hard-pressed had an increased risk of graft failure within 5 years compared with the least deprived patients.
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http://dx.doi.org/10.1016/j.ophtha.2013.07.050DOI Listing
December 2013

Rheumatoid arthritis-associated corneal ulceration: mortality and graft survival.

Ophthalmology 2013 Apr 3;120(4):682-6. Epub 2013 Jan 3.

St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.

Purpose: To investigate mortality and graft survival in patients undergoing penetrating keratoplasty (PKP) for rheumatoid arthritis-associated corneal ulceration (RACU), Fuchs' endothelial dystrophy (FED), and pseudophakic bullous keratopathy (PBK).

Design: Case-control study.

Participants And Controls: Patients listed on the UK Transplant Registry who had undergone a PKP for RACU, FED, or PBK between January 4, 1999, and January 4, 2006. Comparative standardized mortality ratios (SMRs) and causes of death were obtained from the Office for National Statistics.

Methods: Outcome data were collected from the UK Ocular Tissue National Transplant database and supplementary questionnaires at transplantation and at 1, 2, and 5 years. Institutional review board approval for the National Health Service Blood and Transplant to undertake the study was obtained.

Main Outcome Measures: Mortality and graft survival.

Results: A total of 3665 patients were included: RACU (117), PBK (1701), and FED (1847). Five-year survival of patients with RACU was 42% (95% confidence interval [CI], 26-56) compared with 76% (95% CI, 72-78) for FED and 55% for PBK (95% CI, 50-60; P < 0.01). The SMRs for female and male patients with RACU were 43.5 (95% CI, 19.5-63.3) and 12.2 (95% CI, 7.1-19.5), respectively, in comparison with 1.84 and 1.45 for patients with RA, respectively (P < 0.01). There were no significant differences in the causes of death among patients with RACU, FED, or PBK (P > 0.9), with infection the most common cause. The 5-year graft survival rate was 48% (95% CI, 32-62) for RACU, 59% (95% CI, 56-62) for PBK, and 84% (95% CI, 82-86) for FED (P < 0.01).

Conclusions: Mortality and ocular morbidity were significantly increased in patients with RACU. Accelerated immunosenescence should be considered in the differential diagnosis of patients presenting with RACU, and a multidisciplinary approach to management is required.
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http://dx.doi.org/10.1016/j.ophtha.2012.09.050DOI Listing
April 2013

Trends in the indications for corneal graft surgery in the United Kingdom: 1999 through 2009.

Arch Ophthalmol 2012 May;130(5):621-8

School of Biomedicine, Faculty of Medical and Human Sciences, University of Manchester, Manchester, England.

Objective: To examine trends in the indications for corneal graft surgery in the United Kingdom.

Methods: National Health Service Blood and Transplant data were analyzed for keratoplasty operations performed in the United Kingdom between April 1, 1999, and March 31, 2009, distinguishing the type of graft and the surgical indication.

Results: The total number of annual keratoplasty operations increased from 2090 in 1999-2000 to 2511 in 2008-2009. Among these, the annual number of grafts performed for endothelial failure increased from 743 (35.6%) in 1999-2000 to 939 (37.4%) in 2008-2009. The performance of penetrating keratoplasty (PK) for endothelial failure decreased from 98.3% of all grafts in 1999-2000 to 46.6% of all grafts in 2008-2009, while the performance of endothelial keratoplasty increased from 0.3% of all grafts in 1999-2000 to 51.2% of all grafts in 2008-2009. The annual number of grafts performed for keratoconus increased from 514 (24.6%) in 1999 to 564 (22.5%) in 2008-2009. The performance of PK for keratoconus decreased from 88.4% of all grafts in 1999-2000 to 57.1% of all grafts in 2008-2009, while the performance of deep anterior lamellar keratoplasty increased from 8.8% of all grafts in 1999-2000 to 40.1% of all grafts in 2008-2009. The number of annual regraft operations increased from 249 (11.9%) in 1999-2000 to 401 (16.0%) in 2008-2009, most commonly for endothelial failure. In 2008-2009, PK regrafts (78.1%) far outnumbered endothelial keratoplasty regrafts (17.0%).

Conclusions: Endothelial failure is the most common indication for keratoplasty in the United Kingdom, and endothelial keratoplasty is performed more commonly than PK for this indication. The number of grafts performed for pseudophakic bullous keratopathy has remained stable, while the number of grafts performed for Fuchs endothelial dystrophy is likely to continue increasing. Keratoconus is the second most common indication for keratoplasty, and deep anterior lamellar keratoplasty numbers are approaching those for PK. Regraft surgery is the third most common indication for keratoplasty, required in most cases because of endothelial failure.
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http://dx.doi.org/10.1001/archophthalmol.2011.2585DOI Listing
May 2012

Effect of glaucoma on corneal graft survival according to indication for penetrating keratoplasty.

Am J Ophthalmol 2011 Feb 18;151(2):257-62.e1. Epub 2010 Dec 18.

St Paul's Eye Unit, Royal Liverpool Hospital, Liverpool, United Kingdom.

Purpose: To determine whether the risk of graft failure in patients with glaucoma is dependent on the indication for penetrating keratoplasty (PK).

Design: Retrospective cohort study.

Methods: All patients on the United Kingdom Transplant Registry undergoing their first PK over a 7-year period with at least 1 year of follow-up were included. Data were collected on indication for PK, presence and management of glaucoma, graft diameter, recipient risk factors, and graft survival. Kaplan-Meier survival curves, a Cox regression model, and χ(2) and t tests were used in group comparisons.

Results: A total of 6255 transplants in eyes without glaucoma and 1994 in eyes with glaucoma were analyzed. Three-year transplant survival was 86% and 72% respectively (P < .0001), and 73% in eyes with medically managed glaucoma compared to 63% in surgically managed glaucoma (P = .07). Glaucoma patients undergoing PK for pseudophakic bullous keratopathy or Fuchs dystrophy had significantly increased relative risks of graft failure (1.5 and 1.9 with topical and 2.0 and 3.1 with oral antiglaucoma medication respectively, compared to those without glaucoma). There was no equivalent significant difference for those with keratoconus, previous noncataract ocular surgery, trauma, or noninfectious ulcerative keratitis. Endothelial decompensation accounted for a significantly greater proportion of graft failure in recipients with glaucoma (topical [9%] and oral medication [13%]) than in those without glaucoma (3%) (P < .001).

Discussion: The presence of glaucoma carries an increased risk of graft failure, in particular from endothelial decompensation. This risk is, however, also dependent on the indication for PK, with transplants undertaken for primary corneal endothelial disease carrying a higher risk.
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http://dx.doi.org/10.1016/j.ajo.2010.08.018DOI Listing
February 2011

Centre-specific variation in corneal transplant outcomes in the United Kingdom.

Transplantation 2011 Feb;91(3):354-9

Cornea & External Diseases Service, Moorfields Eye Hospital, London, United Kingdom.

Background: To examine the influence of center or surgeon transplant workload on corneal transplant outcome.

Methods: In this database study, centers were categorized as high or low volume if registering more than 50 and less than 10 corneal transplants per year, respectively; surgeons were categorized as high or low volume if registering more than 30 and less than 10 transplants per year, respectively. The participants were patients aged at least 17 years receiving a first penetrating keratoplasty for keratoconus, Fuchs' endothelial disease, or pseudophakic corneal edema in a 7-year period from 1999 in (1) high-volume (n=1724) and low-volume (n=2131) centers and (2) under care of high-volume (n=1332) and low-volume (n=1949) surgeons. Main outcome measures were (1) graft survival at 5 years and (2) 2-year posttransplant best-corrected and day-to-day visual acuity and astigmatism.

Results: No significant difference in graft survival was found according to center or surgeon workload. Statistically significantly better day-to-day visual acuity was found only in patients with Fuchs' endothelial disease managed by high-volume surgeons (20/40 or better in 50% vs. 42% for low-volume surgeons). There was statistically significantly better best-corrected visual acuity in high-volume centers for Fuchs' endothelial disease and pseudophakic corneal edema and for high-volume surgeons in all disease groups.

Conclusions: Based on this national transplant cohort, when analyzed according to center volume or surgeon transplant workload, there is no variation in graft survival and only minor variation in transplant functional outcome.
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http://dx.doi.org/10.1097/TP.0b013e318201ac62DOI Listing
February 2011

Trends in corneal graft surgery in the UK.

Br J Ophthalmol 2011 Apr 27;95(4):468-72. Epub 2010 Jun 27.

Manchester Royal Eye Hospital, Manchester M13 9WH, UK.

Aims: The aims of this study were to examine trends over time and regional variation in rates of corneal graft surgery in the UK.

Methods: The hospital in-patient enquiry (HIPE) and hospital episode statistics (HES) were analysed for keratoplasty admissions in England from 1971 to 2006. NHS Blood and Transplant (NHSBT) data were analysed for keratoplasty operations in the UK from 1999 to 2009.

Results: Annual rates of penetrating keratoplasty (PK) under HIPE and HES increased from 0.7 per 100,000 population (1971) to 3.9 (1992), then decreased to 3.1 (2006). Rates of lamellar keratoplasty (LK) increased from 0.1 (1971) to 0.9 (2006). Annual PK operations under NHSBT decreased from 1901 (1999/00) to 1473 (2008/9). Over the same period, deep anterior lamellar keratoplasty operations increased from 91 to 327 per year, while endothelial keratoplasty operations increased from 2 to 569 per year. Geographical analysis showed a wide variation across local authority areas in rates of keratoplasty around 1998-2004, especially for LK.

Conclusion: The total number of corneal graft operations performed in the UK has increased slowly over the past decade. The proportion of lamellar versus penetrating keratoplasty has increased, with LK performed at the highest rates in specialist centres distributed across the UK.
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http://dx.doi.org/10.1136/bjo.2010.182329DOI Listing
April 2011

Sequential versus combined penetrating keratoplasty and cataract surgery.

Optom Vis Sci 2010 Jul;87(7):482-6

Ophthalmology Department, St Paul's Eye Unit, Royal Liverpool University Hospital, Prescott Street, Liverpool L7 8xP, United Kingdom.

Purpose: To compare the refractive and visual outcomes of combined penetrating keratoplasty and cataract surgery (triple procedure) with those of sequential surgery (penetrating keratoplasty followed by secondary cataract extraction and posterior chamber intraocular lens implantation).

Methods: Forty-six consecutive patients undergoing triple procedure or sequential surgery performed by two surgeons were reviewed retrospectively. The triple procedure group consisted of 23 patients and the sequential surgery group also consisted of 23 patients. Refractive and visual outcomes were collected and analyzed with at least 1 year of follow-up for both groups. Both the difference from target and the variability of the refractive outcome were analyzed.

Results: Best spectacle corrected visual acuity of 6/12 or better was achieved in 16 eyes (69.8%) in the triple procedure group and in 19 eyes (82.6%) in the sequential surgery group. For both the triple and sequential groups, there was no difference between the mean postoperative refractive outcome (-2.73/+1.05 x 109 SD = 4.30/1.42/4.43) and (-1.33/+0.79 x 175 SD = 2.39/1.16/2.33) compared with the mean target refraction (-0.77, SD = 1.16 and -0.43, SD = 0.99), (p = 0.39 and 0.48), respectively. In addition, there was no significant difference in the variability of the refractive outcome between the two groups (p > 0.99).

Conclusions: Sequential surgery appears to offer no significant advantages over the triple procedure in terms of refractive predictability or variability. There was a slight trend toward more patients achieving 6/12 or better vision in the sequential group.
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http://dx.doi.org/10.1097/OPX.0b013e3181e1728eDOI Listing
July 2010

Long-term topical steroid treatment after penetrating keratoplasty in patients with pseudophakic bullous keratopathy.

Ophthalmology 2009 Dec 7;116(12):2369-72. Epub 2009 Oct 7.

Bristol Eye Hospital, Bristol, United Kingdom.

Purpose: To assess the use of long-term topical corticosteroid treatment in patients with pseudophakic bullous keratopathy (PBK) after penetrating keratoplasty (PK).

Design: Retrospective cohort study.

Participants: This study considered patients with PBK undergoing an initial PK procedure for visual reasons in the United Kingdom between April 1999 and March 2004. There were 1274 initial PK procedures for PBK reported to United Kingdom Transplant in this period, of which 1184 (91%) were grafted for visual reasons. Of these 1184 grafts, follow-up was reported in 1033 instances (87%).

Methods: A Cox regression model was used to investigate the combined effects of all preoperative factors (recipient age, human leukocyte antigen [HLA] matching, trephine size, deep stromal vascularization, surgeon activity) on graft failure. The model was fitted using all preoperative factors first, and subsequently, factors associated with corticosteroid and other medications were included.

Main Outcome Measures: Graft survival.

Results: Three-year survival of grafts for PBK was 65% (95% confidence interval [CI], 59%-70%). Topical corticosteroids were still being used beyond 18 months after surgery in 378 (37%) of the 1033 corneal grafts included in this study. The grafts of patients not currently receiving steroids were 1.5 times as likely to fail (hazard ratio [HR], 1.5; 95% CI, 1.0-2.2; P<0.03). Lack of HLA matching (P = 0.006), trephine size or=8.00 mm (P = 0.03), recipient age younger than 65 years (P = 0.003), and corneal vascularization (P = 0.04) all increased the risk of graft failure.

Conclusions: The use of long-term postoperative corticosteroids improved graft survival after PK for PBK. Barring patient contraindications for long-term topical corticosteroid use, clinicians should consider maintaining patients with PBK on long-term postoperative corticosteroid maintenance.
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http://dx.doi.org/10.1016/j.ophtha.2009.06.006DOI Listing
December 2009

Penetrating and deep anterior lamellar keratoplasty for keratoconus: a comparison of graft outcomes in the United kingdom.

Invest Ophthalmol Vis Sci 2009 Dec 6;50(12):5625-9. Epub 2009 Aug 6.

NHS Blood and Transplant, Bristol, United Kingdom.

Purpose: To compare outcomes after penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) for keratoconus in the United Kingdom.

Methods: Patient outcome data were collected at the time of transplantation and at 1, 2, and 5 years after surgery. Data were analyzed by Kaplan-Meier survival curves, Cox regression, and binary logistic regression to determine the influence of surgical procedure on graft survival and visual outcome.

Results: The risk of graft failure for DALK was almost twice that for PK (P = 0.02). Nineteen percent of the DALK failures occurred in the first 30 postoperative days compared with only 2% of PK failures. When these early failures were excluded, there was little difference between the 3-year graft survivals for DALK (92%; 95% confidence interval [CI], 85%-95%) and PK (94%; 95% CI, 92%-95%) (P = 0.8). Although the mean best corrected visual acuity (BCVA) was similar for the two procedures (P = 0.7), 33% of patients who underwent PK achieved a BCVA of 6/6 or better at 2 years compared with only 22% of those who underwent DALK (P < 0.001). Those with DALK were also likely to be more myopic (< -3 D) but there was little difference in scalar cylinder.

Conclusions: DALK had a higher overall failure rate than PK. The difference was largely accounted for by early failures, which appeared to be related to the surgeon's experience. DALK recipients were less likely to achieve BCVA of 6/6 than were PK recipients and were more likely to have -3 D or worse myopia.
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http://dx.doi.org/10.1167/iovs.09-3994DOI Listing
December 2009

Outcomes of same-sizing versus oversizing donor trephines in keratoconic patients undergoing first penetrating keratoplasty.

Ophthalmology 2008 Feb;115(2):268-75

Bristol Eye Hospital, Bristol, United Kingdom.

Purpose: To investigate whether use of same-size donor and recipient trephines reduced myopia after penetrating keratoplasty for keratoconus.

Design: Retrospective cohort study.

Participants: Eight hundred seventy-eight first grafts for keratoconus were reported to UK Transplant between April 1999 and December 2003. There were 234 and 644 grafts in the same-size and oversize donor trephine groups, respectively. At 1 year, mean spherical equivalent (SE) data were available for 116 eyes (50%) and 295 eyes (46%) in the same-size and oversize groups. At 2 years, mean SE data were available for 64 eyes (27%) and 148 eyes (23%) in the same-size and oversize groups.

Methods: Logistic regression and univariate analysis of follow-up data submitted to UK Transplant.

Main Outcome Measures: At 1 and 2 years postoperatively, mean SE, magnitude of the cylindrical component of the refraction, postoperative uncorrected visual acuity (VA), postoperative best-corrected VA, and postoperative complications were recorded.

Results: The mean SEs for the same-size and oversize donor trephine groups, respectively, were -1.45 diopters (D) and -1.41 D at 1 year (P = 0.6) and -1.74 D and -2.19 D at 2 years postoperatively (P = 0.3). Although there were no differences in graft survival between the groups at 1 and 2 years, there was a higher incidence of postoperative wound leaks in the same-size group (P = 0.03).

Conclusion: Use of same-size donor and recipient trephines did not reduce myopia and was associated with an increased risk of postoperative complications.
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http://dx.doi.org/10.1016/j.ophtha.2007.04.051DOI Listing
February 2008

Will transplantation of kidneys from donors with blood group A2 into recipients with blood group B help British Indo-Asian patients with renal failure?

Transplantation 2004 Feb;77(4):630-3

Renal Section, Division of Medicine, Hammersmith Campus, Imperial College London, United Kingdom.

Despite a high incidence of renal failure, disproportionately fewer Indo-Asians in the United Kingdom receive a renal transplant, in part because of the high prevalence of blood group B. It is now clear that it is possible to safely transplant kidneys from donors with blood group A of the subtype A2 into recipients with blood group B if the latter have low titers of anti-A antibodies. We measured the anti-A titers in 25 Indo-Asian patients on dialysis being considered for transplantation and found stably low titers in all. Titers were comparable to those found in a control white population with blood group B. In addition, in a complement-dependent cytotoxicity crossmatch against group A lymphocytes, the only positive results were obtained in those with high preexisting panel reactivity (i.e., because of the presence of preformed anti-human leukocyte antigen antibodies). We conclude that there are grounds for investigating this approach further to solve the ethnic disparity in rates of transplantation.
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http://dx.doi.org/10.1097/01.tp.0000103728.05798.7eDOI Listing
February 2004