Post-keratoplasty Medical Management: Survey of Current Practice Patterns in the Philippines

Background. Optimizing postoperative management to reduce complications and prolong graft survival after corneal transplantation is essential to reduce the demand for corneal tissue. While studies in developed countries have focused on steroid use, limited attention has been given to antibiotic prophylaxis. 

Objective. To address this gap, we conducted a survey among corneal surgeons in the Philippines to determine the practice patterns for steroid and antibiotic use in the postoperative management of various keratoplasty types, as well as the initial strategies for managing ocular hypertension and graft rejection.

Methods. A cross-sectional online survey was distributed to cornea surgeons accredited by the Eye Bank Foundation of the Philippines, Inc. (EBFPI). The survey included questions regarding practice settings, postoperative steroid and antibiotic regimens, and management of ocular hypertension and graft rejection. Responses were collected through Jotform (Jotform Inc., San Francisco, CA) from September 24 to October 8, 2024, and analyzed using descriptive statistics.

Results. A total of 58 corneal surgeons responded (85% response rate), representing 12 regions in the Philippines. Most respondents (45%) had over 15 years of practice. All participants performed penetrating keratoplasty (PKP), followed by deep anterior lamellar keratoplasty (DALK) (33%), Descemet stripping endothelial keratoplasty (DSEK) (24%), and Descemet membrane endothelial keratoplasty (DMEK) (19%). Prednisolone acetate 1% was the preferred topical steroid across all types of keratoplasty, particularly during the first 12 months post-surgery and beyond 12 months for high-risk PKP. The frequency was tapered and maintained once to twice daily beyond 12 months. High-risk PKP received more frequent dosing and slower tapering. Standalone antibiotics were favored over fixed-dose combination antibiotic-steroid eyedrops, with levofloxacin 0.5% as the most preferred topical antibiotic. Most surgeons (55%) continued antibiotics while corneal sutures remained. Most surgeons continued antibiotics at varying frequencies beyond 12 months for PKP (60%) and until 6 months for DALK (63%). For endothelial keratoplasty (EK), antibiotics were used up to one month. For ocular hypertension, 55% of surgeons preferred starting glaucoma medications, primarily beta-adrenergic antagonists (71%). Topical steroids were the initial treatment for graft rejection in both PKP (72%) and lamellar keratoplasty (74%), with 78% of respondents preferring hourly administration.

Conclusion. This study is the first to examine current post-keratoplasty medical management practices in the Philippines. Steroid choice was consistent with previous global surveys, with frequency increasing with rejection risk associated with the keratoplasty type; however, it exceeded the dosing trends observed in the United States. Including questions on post-keratoplasty antibiotic use in the survey provided valuable insights into the current practices. Standalone antibiotics were preferred across all keratoplasty types, with prolonged use in PKP and DALK, likely related to the infection risk from corneal sutures. The initial treatments for ocular hypertension and graft rejection were comparable to those in other studies. The variations in treatment protocols underscore the need for local studies to evaluate outcomes associated with different regimens and highlight the importance of developing local practice guidelines for optimal post-keratoplasty care in the Philippines.