Visual Acuity Worsens Following Re-Bubbling Procedures, Repeat Keratoplasties

Ophthalmologist hand showing letter on eye chart to patient with vision problems
Ophthalmologist hand showing letter on eye chart to patient with vision problems
Older age and female sex were associated with poor visual acuity outcomes in patients with Fuchs endothelial corneal dystrophy who underwent endothelial keratoplasty.

Postoperative re-bubbling procedures and repeat keratoplasties are associated with poor visual acuity (VA) outcomes following endothelial keratoplasty (EK), according to a study published in Ophthalmology. Secondary findings also revealed a link between poor VA outcomes and the demographic factors of older age and female sex in a subgroup of participants with Fuchs endothelial corneal dystrophy (FECD).

Researchers retrospectively analyzed 30,600 eyes of 25,666 patients from 2013 to 2018 (mean age 72.8±10.5 years, 59.2% women, 81.7% White) to determine VA outcomes and risk factors associated with failure to improve after EK. They estimated factors associated with worse VA outcomes, and adjusted for socio-demographic factors, baseline vision, surgical indication, ocular comorbidities, and complications following procedures.

The team noted that VA improved from baseline to 6 month and 1 year postoperative visits for the cohort as a whole (mean logMAR, 0.71±0.53, 0.46±0.40, and 0.44±0.41, respectively). 

They found that 30.3% of the overall cohort, 29.8% of the FECD subgroup, and 27.4% of a subgroup with bullous keratopathy (BK) did not show visual improvement after 1 year. In both subgroups, higher baseline VA was associated with an increased likelihood of postoperative VA improvement (FECD: RR, 0.82; BK: RR, 0.91), while postoperative re-bubble procedures (FECD: RR, 1.10, 95% CI, 1.02-1.19; BK: RR, 1.31, 95% CI, 1.17-1.48) and repeat keratoplasties (FECD: RR, 1.41, 95% CI, 1.32-1.52; BK: RR, 1.42, 95% CI, 1.28-1.57) were linked with a higher risk of worsening or unchanged VA.

A subanalysis of the FECD group revealed that older age (RR, 1.05 per 5-year increase) and female sex (RR, 1.10) were associated with equal or worsening VA at 1-year follow-up.

“The analysis accounted for many potential predictors of VA outcomes, including diagnostic groups, ocular comorbidities, procedures, preoperative VA, and postoperative complications,” according to the researchers. “The data reported here, especially regarding the likelihood of improvement in vision, should be helpful for perioperative counseling.”

Limitations of the study include its retroscopic nature, a high loss to follow-up, failure to account for possible billing errors during enrollment, and lack of standardized VA measurements.


Srikumaran D, Son HS, Li C, et al. Disparities in visual acuity outcomes after endothelial keratoplasty: an IRIS registry analysis. Ophthalmol. Published online April 7, 2022. doi:10.1016/j.ophtha.2022.04.005