Fuchs Treatment Selection Affected By Patient Sociodemographics

Patients with Fuchs endothelial corneal dystrophy (FECD) who are of White ethnicity are more likely to undergo the updated endothelial keratoplasty (EK) procedure, whereas patients who belong to all other racial groups are more likely to be treated with the penetrating keratoplasty (PK) procedure,  according to the results of a study published in Ophthalmology.  The study also shows that patients in older age groups are more likely to be treated with PK than others, and that men are more likely to be treated using either procedure than women with FECD.

The study considered Medicare beneficiaries who were at least 65 years of age and who had a diagnosis of FECD between 2011 and 2019 to evaluate sociodemographic and medical factors associated with receipt of EK or PK. 

The EK approach eclipsed PK for the treatment of FECD in 2020, with 94.5% of patients undergoing keratoplasty for FECD receiving EK and 5.5% receiving PK. FECD has been the most common indication for EK since 2012, researchers explain.

The team used a 100% Medicare fee-for-service administrative claims database to identify treatment-naive patients with a diagnosis of FECD and conducted a multivariable logistic regression analysis that included age, race and ethnicity, sex, geography, ocular comorbidities and surgeries, Charlson comorbidity index (CCI), and socioeconomic status in the model. They also used Kaplan-Meier survival analyses to determine the rate of EK after cataract surgery and complex/other anterior segment surgery.

The researchers identified 719,066 beneficiaries, of whom 4.4% received a first-time EK and 0.3% received a first-time PK. In the multivariate analysis, they found that women had a decreased likelihood of undergoing either EK or PK (EK: adjusted odds ratio [aOR], 0.83; 95% CI, 0.81-0.85; PK: aOR, 0.84; 95% CI, 0.78-0.92). 

Additionally, Southern US residents (EK: aOR, 1.33; 95% CI, 1.29-1.38; PK: 1.25; 95% CI, 1.11-1.42) and and those without a history of complex or other anterior segment surgery (EK: aOR, 1.62; 95% CI, 1.54-1.70; PK: 5.52; 95% CI, 4.97-6.12) were less likely to undergo either procedure than Western residents or those who have had prior anterior segment surgery, respectively. 

Compared with non-Hispanic White patients, the team found that the likelihood of EK was decreased and the likelihood of PK was increased for 3 patient groups divided by ethnicity:Patients who were Black (EK: aOR, 0.76; 95% CI, 0.72-0.80; PK: aOR, 1.32; 95% CI, 1.14-1.53), Patients who were Asian/Pacific Islanders (EK: aOR, 0.54; 95% CI, 0.48-0.61; PK: aOR, 1.46; 95% CI, 1.13-1.89), and Patients who were Hispanic/Latino (EK: aOR, 0.62; 95% CI, 0.55-0.70; PK: aOR, 1.62; 95% CI, 1.25-2.11).

They also found that increasing age (>85 years: aOR, 0.60; 95% CI, 0.58-0.62), Northeastern compared with Southern US residence (aOR, 0.81; 95% CI, 0.78-0.84), and Charlson comorbidity index score of 7+ compared with 0 (aOR, 0.50; 95% CI, 0.44-0.57) were associated with decreasing likelihood of EK.

The study also shows that patients with diabetic retinopathy, age-related macular degeneration, and macular hole or epiretinal membrane have a decreased likelihood of being treated with EK, potentially due to their low potential for visual improvement.

The team found that the rates of EK following cataract or complex or other anterior segment surgery were 1.3% and 3.3% at 1 year and 2.3% and 5.6% at 8 years, respectively.

“While FECD remains the most common indication for EK in the US, the rate of keratoplasty for FECD among Medicare beneficiaries is low,“ the researchers report. “The observation of increased odds of PK in non-White beneficiaries is even more notable when considering that prior studies have demonstrated higher rates of graft rejection among Black or non-White patients and that PK has higher rates of rejection and failure when compared to EK. In these populations, a shift towards performing EK rather than PK may potentially reduce the rates of postkeratoplasty complications such as graft rejection and failure and thus improve outcomes.”

Limitations of the study included inability to corroborate the findings with clinical data or to evaluate or account for disease severity at the time of presentation or surgery, limited ability to assess socioeconomic influences, and potential lack of generalizability to patient populations without Medicare coverage or outside of the age range studied.