Transplante de córnea: tendências e impacto da pandemia de Covid-19

• Autor(a) principal: Moriyama, Aline Silveira [UNIFESP]
• Data de Publicação: 2021
• Tipo de documento: Tese
• Idioma: por
• Título da fonte: Repositório Institucional da UNIFESP
• Texto Completo: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=11155431; https://repositorio.unifesp.br/handle/11600/68312
• topic: Keratoplasty; Lamellar Keratoplasty; Eye Bank; Covid-19; SARS-CoV-2; Ceratoplastia; Ceratoplastia Lamelar; Banco De Olhos; Covid-19; SARS-CoV-2

Objectives: The present thesis aims at evaluating trends of keratoplasty techniques usage at a tertiary center in Brazil, and to study factors that can impact corneal transplant (CT) usage among corneal surgeons, such as surgical training, the possibility of increasing donated tissue availability for lamellar keratoplasty (LK) procedures, and, finally, the severe consequences of COVID-19 pandemic associated restrictions. Methods: 1. Retrospective study evaluating endothelial viability of all tectonic corneas preserved at the Banco de Olhos de Sorocaba and its potential use for EK, by separating those with ECD ≥ 2,000 cells/mm2 and adequate endothelial parameters at slit lamp evaluation. 2. Prospective study evaluating the first 53 DMEK surgeries performed by corneal fellows at HOS/BOS. Post-operative best corrected visual acuity (BCVA), ECD and complications were analyzed. 3. Retrospective trends study regarding the use of different keratoplasty techniques at a tertiary hospital from 2012 to 2019. 4. Journal editorial regarding the potential short- and long-term impact of COVID-19 pandemic on corneal transplantation programs and eye banking from a global perspective, highlighting the main international guidelines and their discrepancies. 5. Retrospective study using data from Hospital Oftalmológico de Sorocaba, from the Banco de Olhos de Sorocaba (HOS/BOS), state of São Paulo and Brazil during the elective corneal transplantation moratorium and after resumption, in comparison to pre-pandemic data. 6. Report of two cases of presumed DMEK graft rejection that occurred during COVID-19 infection. Results: 1. A total of 2,847 preserved corneas was evaluated, of which 423 (14.85%) were classified as tectonic. Of these, 87 (20.56%) were reported as having endothelial viability compatible with EK use. Average corneal endothelial cell density of this group was 2,471 ± 256 cells/mm2, ranging from 2012 to 2967 cells/mm2. 2. Among eyes with full visual potential, 97% achieved a BCVA of ≥ 20/40 in 6 months. The DMEK graft preparation by the surgeons in training was successful in all cases. Nine eyes (17%) experienced partial graft detachment, being successfully managed by rebubbling. Three eyes (5.7%) had graft primary failure, requiring to repeat EK. 3. A total of 16,250 keratoplasties were performed from the 1st of January of 2012 to the 31st of December of 2019. There was a significant trend of reduction of PK (p<0.0001) and ALK (p<0.0001), contrasting to a significant trend of increase of EK, that grew from 7.8% in 2012 to 39.9% in 2019 (p<0.0001). Among EK, DMEK showed a significant trend of growth, rising from 12.8% in 2012 to 74.4% in 2019 (p<0.0001). 4. SARS-CoV-2 transmission via keratoplasty is uncertain, though possible. New criteria for ocular tissue donor and CT recipient screening are needed. 5. There was a significant reduction on keratoplasties numbers during the elective CT moratorium and afterwards in comparison to pre-pandemic data. After resuming elective CTs, among surgeries performed at HOS/BOS, EK declined while PK increased when comparing the period with the rates before pandemic. The number of new patients added to waiting list both at the state of São Paulo and Brazil were comparable after restarting elective CT with those prior to pandemic, leading to a significant growth of total patients on CT waiting list regionally and nationally. 6. Two patients with DMEK surgery secondary to Fuchs dystrophy presented history compatible with graft rejection during COVID-19 infection. Both cases required hospital admission but not orotracheal intubation. Additionally, the two suspended the use of topical steroid while hospitalized. Conclusions: 1. An important number of donor corneas traditionally classified as tectonic display characteristics compatible with EK use. These results supported the development of a new classification system for eye bank corneas in the state of São Paulo, Brazil. 2. Positive results with good surgical outcomes and acceptable complications rates were seen upon establishing a DMEK teaching program as part of a corneal fellowship under the supervision of an experienced DMEK surgeon. 3. Significant trends were observed on different keratoplasty techniques usage trends. A marked EK increase was seen, contrasting with a trend of reduction for PK and ALK. Among EK, DMEK had a rapid growth during the studied period. 4. Further studies and consensus are necessary regarding exclusion criteria of potential donors with suspect, diagnosis or risk factors for COVID- 19, and the utility of RT-PCR as a screening method for donors and recipients. 5. The COVID-19 pandemic had dramatic short- and long-term effects on CTs in Brazil. An estimate increase on the CT number of 34% in São Paulo and 91% in Brazil is required to make the CT waiting list comparable to the pre-pandemic status. 6. The reported cases support a possible association between COVID-19 and CT rejection.