Lost to Follow-up

In a new retrospective study, Dr Sujata Das and others from the L V Prasad Eye Institute Bhubaneshwar examine the declining follow-up rate of corneal transplantees over a three-year period. The paper notes a 78% drop-out rate and identifies factors associated with drop-out in their single-centre, cross-sectional study. 

Corneal opacities and related blindness are a key cause of vision loss in India. In many such cases, corneal transplantation is the primary means of tackling corneal blindness and restoring sight. Transplants are also used for ‘therapeutic’ interventions where the host tissue damaged by microbial action is replaced with donor tissue, thereby reducing microbial load, and improving the cornea’s anatomic integrity. Corneal transplants are believed to have better prospects of long-term success when compared to other transplants because of the cornea’s relative immune privilege. Newer forms of transplant surgery have also improved outcomes. Yet, graft-rejections and failed transplants persist to a higher-than-expected degree. A key reason is not coming back for post-surgery follow-up after a few months. 

Many factors seem to influence this behavior. In therapeutic transplants, patients may not see any big improvement in vision, and this may be disappointing. There may be financial or logistical barriers that prevent patients from coming back for a follow-up. A failed transplant may itself result in loss to follow-up. A corneal infection or inflammation, or a previous failed transplant has a higher risk of rejection, for example. In 1997, LVPEI researchers published an analysis on the survival rate of corneal transplants in India. The study discussed several pre-operative risk factors, including congenital causes, which could lead to poor outcomes. Apart from being multifactorial, loss to follow-up may also depend on the location of services rendered and the type of corneal transplant. It is important then to capture follow-up rate in different locations along with the pattern there. 

A new, single‐centre, retrospective cross‐sectional study in the Indian Journal of Ophthalmology by Drs Sujata Das, Anirban Dutta, and others from LVPEI investigate the pattern of follow-up loss among corneal transplant patients in Bhubaneshwar. The study split 163 patients (165 eyes) who underwent corneal transplantation into two groups: those who adhered to follow-up visits over a 3-year period and those who did not. The cohort’s median age was 52 (maximum 65 years) and a majority (67.5%) were male. For about 23% of the patients, the transplanted eye was the only functional eye. At the three-year mark (36 months), 129 eyes (78.2%) were in the ‘lost-to-follow-up’ group. 

Beginning at 68% at 6 months, the follow-up rate fell to 35.2% by the third year in this cohort. The lost to follow-up in this cohort then is the highest recorded in literature from low-income countries on corneal transplant outcomes. The study found that older age, prior graft failure, and poorer visual acuity in the last visit had a strong association with dropping out of follow-up. Longer distances from the hospital also had a strong association with drop-off rate. The paper raises many important questions on what it takes to bring people back to the clinic. It offers some solutions, including tele-ophthalmic follow-up. 

‘While planning for a cornea transplant, many social factors should be taken into consideration along with corneal pathology/disease,’ notes Dr Sujata Das, consultant ophthalmologist, LVPEI Bhubaneshwar and the corresponding author of this paper. ‘Technology like teleophthalmology may help to decrease the lost-to-follow-up rate in future.’ 

Citation
Dutta A, Panigrahi SP, Mohamed A, Das S. Lost‐to‐follow‐up: A study on corneal transplantation from Eastern India. Indian J Ophthalmol 2023;71:1877‐81. 

Photo credit: Kamagara Bridge Over Brahmani River; Photo by Biswarup Ganguly; CC BY 4.0.