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Clinical characteristics and risk factors for readmission after deep anterior lamellar keratoplasty: a nationwide, cross-sectional, multicenter study

BMC Ophthalmology volume 25, Article number: 193 (2025) Cite this article

Abstract

Background

To assess the incidence, cause and risk factors for unplanned readmission within 90 days after deep anterior lamellar keratoplasty (DALK).

Methods

A multicentre cross-sectional study of 3603 eyes of 3588 patients after keratoplasty between January 1st, 2019, and September 30th, 2021 in 16 hospitals across China was performed. The demographic and clinical features between patients after DALK with 90-day unplanned readmission and those who did not have been compared. The risk factors of unplanned readmission were identified by a multivariable Cox regression model.

Results

Among 873 patients (878 eyes) after DALK, and the primary indications for DALK were keratitis (391 eyes, 44.53%) and keratoconus (275 eyes, 31.32%). The rates of unplanned readmission within 30 days, 60 days, and 90 days were 1.95%, 4.01%, and 5.15%. The main reason of 90-day readmission was infectious keratitis (18 eyes, 40.00%), followed by corneal epithelial defects (11 eyes, 24.44%) and immune-related keratitis (10 eyes, 22.22%). Patients readmitted within 90 days exhibit a more advanced age (p = 0.013). It is also more concentrated in patients with corneal ulcers or perforations (p = 0.029) or blindness (p = 0.02). Compared with patients with keratoconus, patients with keratitis (HR = 3.545, 95% CI 1.104–11.386, p = 0.034) and corneal degeneration or malnutrition (HR = 6.470, 95% CI 1.942–21.560, p = 0.002) are more likely to have an unplanned readmission risk within 90 days.

Conclusion

The main causes of unplanned readmission within 90 days after DALK were infectious keratitis, corneal epithelial defects, and immune-related keratitis. The indications for DALK were associated with 90-day readmissions.

Clinical trial number

Not applicable.

Peer Review reports

Background

According to World Health Organization(WHO) data, corneal diseases were identified as the fifth leading cause of global blindness in 2015 [1], particularly in developing countries [2, 3]. As a refined therapeutic keratoplasty, deep anterior lamellar keratoplasty (DALK) preserves the healthy host endothelium while selectively replacing pathological corneal stroma, which is frequently employed in the treatment of infectious keratitis, keratoconus and corneal scars [4,5,6].

Compared with penetrating keratoplasty (PK), DALK establishes an anatomically continuous graft-host interface that significantly improves visual acuity outcomes, while improving the long-term graft survival rate through avoidance of endothelial rejection and host endothelial cell loss [7,8,9,10]. Furthermore, it effectively reduces the severe complications of open intraocular surgery, requires a shorter duration of postoperative corticosteroid use, exhibits greater resistance to globe rupture after blunt trauma, facilitates earlier suture removal. Lastly, DALK allows for one or multiple individuals to share a single donor cornea that optimizing the utilization of corneal tissue resources [11]. However, a meta-analysis in 2016 indicated that lamellar keratoplasty (LK) comprised only 29.7% of all keratoplasty procedures globally, with 31 countries (33%) reporting no implementation of LK [12]. In conclusion, due to its higher surgical skill requirements and longer learning curve for surgeons, the current implementation of this technique remains somewhat limited [13].

However, DALK is also associated with the risk of graft failure attributable to postoperative complications such as infection, delayed corneal re-epithelialization, epithelial and stromal rejection, recurrence of primary diseases, and persistent double anterior chamber and graft-host interface problems (opacification, irregularity and/or neovascularization) [14, 15]. In severe cases, patients necessitate unplanned rehospitalization, including some requiring multiple keratoplasties [16]. Unplanned rehospitalization significantly impacts both individual patients and the healthcare system, negatively influencing resource utilization and increasing expenditure [17]. It also serves as a pivotal benchmark widely used internationally to assess healthcare quality and service levels [18,19,20]. A study conducted in the United States from 2007 to 2011 revealed that readmissions cost the U.S. government over $17 billion annually [21], with up to three-quarters of readmissions being preventable [22]. The majority of studies on hospital readmissions are unrelated to ophthalmology [23,24,25,26], however, a study on 30-day unplanned readmissions in pediatric ophthalmology in the Middle East in 2015 revealed that three of the top five reasons for readmission were related to complications following corneal suturing, typically in the context of keratoplasty [27]. This highlights that patients undergoing keratoplasty are at an elevated risk of readmission in ophthalmology, necessitating enhanced post-discharge follow-up and attention. Current research has affirmed that surgery-related complications are the primary cause of unplanned rehospitalization postoperatively [28, 29], effective strategies in this area can contribute to improving healthcare quality and alleviating economic burdens.

Currently, existing studies often focus on postoperative complications in DALK patients and the graft survival rate several years later [30,31,32,33,34,35,36,37]. However, unplanned readmissions within 90 days following deep anterior lamellar keratoplasty typically indicate severe postoperative complications, including but not limited to infections, graft rejection, or even necessitating repeat keratoplasty or enucleation. These high-risk events not only adversely affect visual prognosis but also exacerbate the strain on scarce corneal donor resources. Therefore, this study aims to evaluate the incidence of unplanned readmissions within 30 days, 60 days, and 90 days after DALK, describe the clinical characteristics and reasons for readmission, and identify the risk factors related to 90-day readmission.

Methods

Study design and participants

As a multicenter, retrospective, observational study conducted in 16 tertiary hospitals in 15 provinces across China. All patients who underwent keratoplasty between January 1st, 2019, and September 30th, 2021 were consecutively included, the admission associated with the first keratoplasty procedure was considered the index admission, while those patients who missing crucial medical record data(admission records, discharge records and surgery record) were excluded. We selected patients after DALK for further analysis. DALK is defined as the keratoplasty that removes the complete stroma while leaving behind only bare Descemet’s membrane and endothelium. We divided the patients into two groups: those who readmitted within 90 days after discharge due to post-DALK complications, and those who did not. A comparison of demographic and clinical characteristics between the groups was performed, along with an analysis of associated risk factors. Rehospitalization medical records were collected from the same hospitals within 90 days after index admission to describe the cause for readmission. If patients were readmitted multiple times during this period, only the first readmission were included for retrospective analysis.

The study was approved by the ethics committee of Eye Hospital, Wenzhou Medical University, Zhejiang, China (approval no.2020-217-K-197-01). Otherwise, the study protocol was approved by the ethics committee at each participating centre, the study used data collected from inpatient medical records while maintaining patient anonymity, and the institutional review board approved waiver of patient informed consent.

Data collection, handling, and storage

Clinical data were collected by one or more trained physicians in each center from inpatient medical records (paper or electronic). Specific data collection items include demographics characteristics (age, gender, residence, ethnicity, healthcare insurance payment status and others), disease diagnoses (admission and discharge), clinical characteristics (vision acuity, corneal signs, course of disease, the length of hospitalization and others), past medical history (history of ocular diseases, ocular surgeries, ocular trauma, systemic diseases and others), test and examinations, treatment choices and medical costs. The corresponding medical records data were entered into an Electronic Data Capture (EDC) platform specifically created for this study (https://www.realdata.net.cn/). A standardized Case Report Form (CRF) specific to this study has been preloaded onto the platform. All center-specific medical records are numbered and entered following the prescribed steps mentioned above. The platform’s backend system harmonizes the structured data forms and exports the data in a unified manner. All collected data align with the medical records stored in each center’s archives, ensuring traceability.

Outcomes

The incidence and reasons for unplanned readmission within 90 days after DALK were the main outcomes of this study. The clinical features and risk factors associated with unplanned readmission within 90 days after DALK were secondary outcomes.

Statistical analysis

SPSS software version 25.0 was used for statistical analysis. Descriptive statistics were used to summarize the data. Continuous variables following a normal distribution were expressed as mean ± standard deviation, while non-normally distributed variables were presented as median. Categorical variables were reported as proportions. For normally distributed count data, t-tests were used for comparisons. The Mann-Whitney U test is utilized to examine non-normally distributed count data. Chi-square test were used for categorical count data. To identify the risk factors associated with unplanned readmission within 90 days after DALK, univariate Cox regression analysis were conducted to screen for independent variables firstly. Variables with a p-value < 0.05 were included in the multivariate Cox regression analysis. The Log-Rank test (Mantel-Cox test) was utilized to compare the non-readmission rates of the two groups. In all analyses, a p-value < 0.05 was considered to be statistically significant.

Results

Centres and the number of deep anterior lamellar keratoplasty

3588 patients (3603 eyes) after keratoplasty were included in this study. Among these clinical centers, 7 were specialized eye hospital, and 9 were general hospitals. Furthermore, based on the classification of Chinese three economic regions, 6 centers were located in the western region, 4 in the middle region, and 6 in the eastern region (Supplemental Fig. 1).

Among them, 878 cases were DALK, accounting for 24.37% of the total. The number and proportion of DALK varied greatly among different regions, the proportion of DALK in hospitals in the eastern region was 31.60%, 17.29% in the middle region, and 20.69% in the western region (Supplemental Table 1).

Baseline characteristics of deep anterior lamellar keratoplasty patients

Table 1 shows the demographic characteristics of the patients. In this study, the majority of DALK patients were male (574, 65.75%), and the median (interquartile range) age was 41 (22,57) years. The majority of patients were of the Han nationality (851, 97.48%), resided in rural areas (551, 63.12%), and were covered by medical insurance (446, 51.09%). Compared to those in the non-readmission group, the group of unplanned readmission within 90 days was significantly older (p = 0.013).

Table 1 Demographic characteristics of the deep anterior lamellar keratoplasty patients
Full size table

The indications for deep anterior lamellar keratoplasty

The study included a total of 873 DALK patients with 878 eyes, among which 39 eyes (4.44%) underwent repeat keratoplasty. As shown in Fig. 1, the main indications for DALK were keratitis (391 eyes, 44.53%), followed by keratoconus (275 eyes, 31.32%), corneal degeneration or dystrophy (88 eyes, 10.02%), corneal tumors (60 eyes, 6.83%), corneal injuries (45 eyes, 5.13%), and others (19 eyes, 2.16%). The specific disease classification of indications are shown in Supplemental Table 2.

Fig. 1
figure 1

Distribution of the indications for deep anterior lamellar keratoplasty (number of eyes, %)

Full size image

Unplanned readmission rates within 30 days, 60 days, and 90 days after deep anterior lamellar keratoplasty

The unplanned readmission rate within 30 days was 1.95%, within 60 days was 4.01%, and within 90 days was 5.15%. The number of unplanned readmissions reached half of the 90-day total on the 38th day, showing an overall increasing trend followed by a stable phase (Supplemental Fig. 2).

The unplanned readmission rates varied among different indications for DALK, as shown in Fig. 2. The unplanned readmission rates within 90 days, from highest to lowest, were corneal degeneration or dystrophy (9.41%), keratitis (7.16%), corneal injuries (6.67%), corneal tumor (3.33%), and keratoconus (1.47%).

Fig. 2
figure 2

Readmission rate of deep anterior lamellar keratoplasty patients (%). *Readmission rate is defined as the number of unplanned readmissions of patients with a certain type of disease within 90 days /the total number of first-time admissions of patients with this type of disease

Full size image

Causes of unplanned readmission within 90 days after deep anterior lamellar keratoplasty

There were 45 patients with 45 eyes who had unplanned readmissions within 90 days in this study. As shown in Fig. 3, infectious keratitis was the most common cause of readmission (18 eyes, 40.00%), followed by corneal epithelial defects (11 eyes, 24.44%) and immune-related keratitis (10 eyes, 22.22%). Additionally, other causes of readmission were the presence of a Descemet membrane or endothelium detachment (2 eyes, 4.44%), loose sutures or removal of sutures (2 eyes, 4.44%), trauma (1 eye, 2.22%), and unknown graft opacity (1 eye, 2.22%). The anterior segment photographed images of patients at readmission were shown in Supplemental Fig. 3. The causes of readmission among patients with different indications for corneal transplantation are showed in the Supplementary Fig. 4.

Fig. 3
figure 3

Cause of 90-days unplanned readmission after deep anterior lamellar keratoplasty (number of eyes, %)

Full size image

Among the 18 patients who were readmitted due to infectious keratitis, the diagnosis or culture results confirmed the pathogen in 15 eyes. The most common identified pathogens included bacterium (5 eyes, 11.11%) and fungus (5 eyes, 11.11%).

Clinical characteristics of deep anterior lamellar keratoplasty patients at index admission

The clinical characteristics of DALK patients during their index admission were shown in Table 2. In terms of the distribution of indications, keratitis is more common in the readmission group (p = 0.014), while the proportion of patients with keratoconus was lower (p = 0.001). Regarding disease features, patients in the readmission group had a relatively shorter disease course (p = 0.001 and p < 0.001). Furthermore, more patients presenting with corneal ulcers or perforation on admission (p = 0.029) and blindness (p = 0.02). The hospitalization time of the readmission group is also longer (p = 0.048).

Table 2 Clinical characteristics of the deep anterior lamellar keratoplasty patients at index admission
Full size table

Risk factors for unplanned readmission within 90 days after deep anterior lamellar keratoplasty

An analysis of risk factors for unplanned readmission within 90 days after DALK revealed the following results using a multivariable Cox regression model (Table 3): compared to patients with keratoconus, those with keratitis (HR = 3.545, 95% CI 1.104–11.386, P = 0.034) and corneal degeneration or dystrophy (HR = 6.470, 95% CI 1.942–21.560, P = 0.002) had a higher risk of unplanned readmission within 90 days.

Table 3 Risk factors for unplanned 90-days readmission of the deep anterior lamellar keratoplasty patients
Full size table

Discussion

The aim of this study was to investigate the rate, clinical characteristics and risk factors associated with unplanned readmission within 90 days after DALK. The findings revealed that the main indications for DALK were keratitis, followed by keratoconus. The unplanned readmission rates within 30, 60, and 90 days were 1.95%, 4.01%, and 5.15%, respectively. Infectious keratitis were the most common cause of unplanned readmission within 90 days, followed by corneal epithelial defects and immune-related keratitis. The indications for DALK were associated with a greater risk of unplanned readmission within 90 days.

In our study, the most common indications for DALK were keratitis, followed by keratoconus and corneal degeneration or dystrophy, which differs from the distribution of indications for corneal transplantation in other countries [12, 13, 38, 39], mainly due to the fact that infectious keratitis is the main cause of corneal blindness in China [40, 41]. Our research found that that compared to patients with keratoconus, patients with keratitis and degeneration with malnutrition were more prone to unplanned readmission within 90 days. These findings collectively suggest a close association between keratoplasty indications and readmission. Indications are the major prognostic factors for graft survival after keratoplasty and are among the most important associated risk factors [42, 43]. According to a 2018 Australian corneal transplant registry report study, patients with keratoconus as the indication for keratoplasty demonstrated significantly higher graft survival rates (91% of patients had graft survival at 8 years). Conversely, patients with corneal ulcer or perforation, a history of previous failed keratoplasty, and bullous keratopathy had the lowest graft survival rates (51%, 63%, and 63% graft survival at 8 years, respectively) [44]. Additionally, keratoplasty indications with poor outcomes often have high-risk factors associated with failure, including active ocular inflammation, corneal neovascularization, and ocular comorbidity (e.g. glaucoma) [45,46,47]. Our research indicated that patients with corneal degeneration or dystrophy and keratitis had higher readmission rates within 90 days, whereas patients with keratoconus had the lowest readmission rate.

In this study, unplanned readmission within 90 days after DALK was mainly caused by infectious keratitis (18 eyes, 40.00%) and corneal epithelial defects (11 eyes, 24.44%). Previous studies have shown that most patients undergoing LK experience varying degrees of corneal superficial abnormalities in the first month after surgery [48, 49]. The mechanisms include corneal nerve damage, long-term use of topical corticosteroids, frequent exposure to toxic topical remedy, poor corneal surface wetting, and anatomical changes in the cornea and graft interface after keratoplasty. These factors contribute to difficulties in epithelialization, resulting in impaired epithelial barrier function and susceptibility to complications that can severely damage vision. Additionally, exposed or loose sutures can disrupt the corneal epithelial surface barrier, thereby aiding microorganisms in entering the corneal stroma [48, 50, 51]. Furthermore, DALK has relatively lenient requirements for the quality of corneal donor tissue. Studies have shown that the use of low-quality corneal donor tissue also increases the incidence of epithelial defects after surgery [52]. Global research shows that there are regional differences in the incidence rate of infectious keratitis after corneal transplantation. The incidence rate in developing countries (9.2–11.9%) is higher than that of developed countries (0.02–7.9%). Bacterial and fungal pathogens are the most common pathogens [53]. Additionally, the increasing number of LK has led to an increase in complications including infectious interface keratitis, resulting in severe visual impairment or blindness [54]. In this study, among the 18 patients readmitted for infectious keratitis after DALK, one eye had concomitant endophthalmitis, whole 6 had severe enough infection to require repeat keratoplasty during readmission period. Relevant literature signifies that common risk factors for postoperative infectious keratitis after keratoplasty encompass the usage of local corticosteroids, suture-related issues, persistent epithelial defects, and prior corneal infections [53, 55, 56]. These findings emphasize the importance of closely monitoring patients with these aforementioned risk factors for postoperative infectious keratitis in future clinical practice. Strengthening postoperative follow-up care is crucial in order to prevent or promptly identify postoperative infections, potentially enhancing graft survival rates and improving prognosis in long term.

A survey study on corneal transplantation in China revealed that the proportion of PK decreased from 57.97% in 2014 to 52.88% in 2018, while the proportion of anterior lamellar keratoplasty increased from 36.04% in 2014 to 37.92% in 2018 [40]. Furthermore, the study suggests that the geographical distribution of corneal transplantation may be related to regional economies, surgical centers in the eastern region have a competitive edge over those in the central and western regions [40]. In our study, DALK accounted for 24.37% of the total number of keratoplasty, and the proportion of DALK in the eastern region was significantly higher than that in the central and western regions, highlighting the substantial disparities in corneal transplantation techniques among different economic regions in China. Moreover, the clinical application of DALK has enabled a single donor cornea to be used for multiple individuals [57], which helps alleviate the disease burden of blindness caused by corneal lesions. Therefore, the effective promotion of widespread and technically proficient training in corneal transplantation, coupled with advanced techniques for optimal utilization of corneal resources, remains a crucial pursuit in the current stage of corneal transplantation in China.

Our research inevitably has some limitations. Firstly, since it is based on hospital records, it only reflects the severe complications leading to unplanned readmission within 90 days after DALK, and the reported complication rates may be lower than the actual occurrence in reality. Secondly, the lack of long-term follow-up data after DALK prevents us from further studying the final visual prognosis and transplant survival rate of DALK. Finally, this study exclusively incorporated readmission records from the same hospital, which may introduce potential omissions. However, the ophthalmic centers included in this study hold significant clinical authority within their respective regions, the omission rate of data remains within an acceptable range.

Conclusions

In conclusions, the main causes of unplanned readmission within 90 days after DALK were infectious keratitis, corneal epithelial defects, and immune-related keratitis. The indications for DALK were associated with 90-day readmissions. Additionally, DALK is still relatively limited in China, and there still exists significant variation across different regions.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

WHO:

World Health Organization

DALK:

Deep Anterior Lamellar Keratoplasty

PK:

Penetrating Keratoplasty

LK:

Lamellar Keratoplasty

HR:

Hazard Ratio

CI:

Confidence Interval

EDC:

Electronic Data Capture

CRF:

Case Report Form

References

  1. Flaxman SR, Bourne RRA, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV, Das A, Jonas JB, Keeffe J, Kempen JH, et al. Global causes of blindness and distance vision impairment 1990–2020: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(12):e1221–34.

    Article  PubMed  Google Scholar 

  2. Liang YB, Friedman DS, Wong TY, Zhan SY, Sun LP, Wang JJ, Duan XR, Yang XH, Wang FH, Zhou Q, et al. Prevalence and causes of low vision and blindness in a rural Chinese adult population: the Handan eye study. Ophthalmology. 2008;115(11):1965–72.

    Article  PubMed  Google Scholar 

  3. Xu L, Wang Y, Li Y, Wang Y, Cui T, Li J, Jonas JB. Causes of blindness and visual impairment in urban and rural areas in Beijing: the Beijing eye study. Ophthalmology. 2006;113(7):e11341131–1111.

    Article  Google Scholar 

  4. Rocha-de-Lossada C, Prieto-Godoy M, Sánchez-González JM, Romano V, Borroni D, Rachwani-Anil R, Alba-Linero C, Peraza-Nieves J, Kaye SB. Rodríguez-Calvo-de-Mora M: tomographic and aberrometric assessment of first-time diagnosed paediatric keratoconus based on age ranges: a multicentre study. Acta Ophthalmol. 2021;99(6):e929–36.

    Article  PubMed  Google Scholar 

  5. Borroni D, Bonzano C, Hristova R, Rachwani-Anil R, Sánchez-González JM, de Lossada CR. Epithelial flap corneal Cross-linking. J Refract Surg. 2021;37(11):741–5.

    Article  PubMed  Google Scholar 

  6. García-López C, Rodríguez-Calvo-de-Mora M, Borroni D, Sánchez-González JM, Romano V, Rocha-de-Lossada C. The role of matrix metalloproteinases in infectious corneal ulcers. Surv Ophthalmol. 2023;68(5):929–39.

    Article  PubMed  Google Scholar 

  7. Buzzonetti L, Ardia R, Petroni S, Petrocelli G, Valente P, Parrilla R, Iarossi G. Four years of corneal keratoplasty in Italian paediatric patients: indications and clinical outcomes. Graefes Arch Clin Exp Ophthalmol. 2016;254(11):2239–45.

    Article  PubMed  Google Scholar 

  8. Yeung SN, Lichtinger A, Kim P, Amiran MD, Rootman DS. Retrospective contralateral study comparing deep anterior lamellar keratoplasty with penetrating keratoplasty: a patient’s perspective. Can J Ophthalmol. 2012;47(4):360–4.

    Article  PubMed  Google Scholar 

  9. Liu H, Chen Y, Wang P, Li B, Wang W, Su Y, Sheng M. Efficacy and safety of deep anterior lamellar keratoplasty vs. penetrating keratoplasty for keratoconus: a meta-analysis. PLoS ONE. 2015;10(1):e0113332.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Reddy JC, Murthy SI, Vaddavalli PK, Garg P, Ramappa M, Chaurasia S, Rathi V, Sangwan VS. Clinical outcomes and risk factors for graft failure after deep anterior lamellar keratoplasty and penetrating keratoplasty for macular corneal dystrophy. Cornea. 2015;34(2):171–6.

    Article  PubMed  Google Scholar 

  11. Heindl LM, Riss S, Bachmann BO, Laaser K, Kruse FE, Cursiefen C. Split cornea transplantation for 2 recipients: a new strategy to reduce corneal tissue cost and shortage. Ophthalmology. 2011;118(2):294–301.

    Article  PubMed  Google Scholar 

  12. Gain P, Jullienne R, He Z, Aldossary M, Acquart S, Cognasse F, Thuret G. Global survey of corneal transplantation and eye banking. JAMA Ophthalmol. 2016;134(2):167–73.

    Article  PubMed  Google Scholar 

  13. Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the American academy of ophthalmology. Ophthalmology. 2011;118(1):209–18.

    Article  PubMed  Google Scholar 

  14. Sugar A, Tanner JP, Dontchev M, Tennant B, Schultze RL, Dunn SP, Lindquist TD, Gal RL, Beck RW, Kollman C, et al. Recipient risk factors for graft failure in the cornea donor study. Ophthalmology. 2009;116(6):1023–8.

    Article  PubMed  Google Scholar 

  15. Tan DT, Dart JK, Holland EJ, Kinoshita S. Corneal transplantation. Lancet. 2012;379(9827):1749–61.

    Article  PubMed  Google Scholar 

  16. Gupta PC, Ram J. Outcomes of repeat keratoplasty for failed therapeutic keratoplasty. Am J Ophthalmol. 2016;169:297–8.

    Article  PubMed  Google Scholar 

  17. Kwok CS, Rao SV, Potts JE, Kontopantelis E, Rashid M, Kinnaird T, Curzen N, Nolan J, Bagur R, Mamas MA. Burden of 30-Day readmissions after percutaneous coronary intervention in 833,344 patients in the united States: predictors, causes, and cost: insights from the nationwide readmission database. JACC Cardiovasc Interv. 2018;11(7):665–74.

    Article  PubMed  Google Scholar 

  18. Thomas JW, Holloway JJ. Investigating early readmission as an indicator for quality of care studies. Med Care. 1991;29(4):377–94.

    Article  CAS  PubMed  Google Scholar 

  19. Milne R. A Clarke 1990 Can readmission rates be used as an outcome indicator? BMJ 301 6761 1139–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Chambers M, Clarke A. Measuring readmission rates. BMJ. 1990;301(6761):1134–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Rohr R. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;361(3):311–2. author reply 312.

    Article  CAS  PubMed  Google Scholar 

  22. Lucas DJ, Pawlik TM. Readmission after surgery. Adv Surg. 2014;48:185–99.

    Article  PubMed  Google Scholar 

  23. Park L, Andrade D, Mastey A, Sun J, Hicks L. Institution specific risk factors for 30 day readmission at a community hospital: a retrospective observational study. BMC Health Serv Res. 2014;14:40.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Li JY, Yong TY, Hakendorf P, Ben-Tovim DI, Thompson CH. Identifying risk factors and patterns for unplanned readmission to a general medical service. Aust Health Rev. 2015;39(1):56–62.

    Article  PubMed  Google Scholar 

  25. Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJ, Arvanitis M, Lohr KN, Middleton JC, Jonas DE. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774–84.

    Article  PubMed  Google Scholar 

  26. Mallick S, Aiken T, Varley P, Abbott D, Tzeng CW, Weber S, Wasif N, Zafar SN. Readmissions from venous thromboembolism after complex cancer surgery. JAMA Surg. 2022;157(4):312–20.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Meeraalam ZA, Khan AO. Reasons for unplanned pediatric readmissions at a referral eye center in the middle East. J Aapos. 2016;20(4):362–4.

    Article  PubMed  Google Scholar 

  28. Kassin MT, Owen RM, Perez SD, Leeds I, Cox JC, Schnier K, Sadiraj V, Sweeney JF. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215(3):322–30.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Lawson EH, Hall BL, Louie R, Ettner SL, Zingmond DS, Han L, Rapp M, Ko CY. Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings. Ann Surg. 2013;258(1):10–8.

    Article  PubMed  Google Scholar 

  30. Lu LM, Boyle AB, Niederer RL, Brookes NH, McGhee CNJ, Patel DV. Repeat corneal transplantation in Auckland, new Zealand: indications, visual outcomes and risk factors for repeat keratoplasty failure. Clin Exp Ophthalmol. 2019;47(8):987–94.

    Article  PubMed  Google Scholar 

  31. Kawashima M, Kawakita T, Shimmura S, Tsubota K, Shimazaki J. Characteristics of traumatic Globe rupture after keratoplasty. Ophthalmology. 2009;116(11):2072–6.

    Article  PubMed  Google Scholar 

  32. Del Alió JL, Bhogal M, Ang M, Ziaei M, Robbie S, Montesel A, Gore DM, Mehta JS, Alió JL. Corneal transplantation after failed grafts: options and outcomes. Surv Ophthalmol. 2021;66(1):20–40.

    Article  PubMed  Google Scholar 

  33. Feizi S, Javadi MA, Khajuee-Kermani P, Jafari R. Repeat keratoplasty for failed deep anterior lamellar keratoplasty in keratoconus: incidence, indications, and outcomes. Cornea. 2017;36(5):535–40.

    Article  PubMed  Google Scholar 

  34. Zafar S, Wang P, Woreta FA, Aziz K, Makary M, Srikumaran D. Risk factors for repeat keratoplasty after endothelial keratoplasty in the medicare population. Am J Ophthalmol. 2021;221:287–98.

    Article  PubMed  Google Scholar 

  35. Sari ES, Koytak A, Kubaloglu A, Culfa S, Erol MK, Ermis SS, Özertürk Y. Traumatic wound dehiscence after deep anterior lamellar keratoplasty. Am J Ophthalmol. 2013;156(4):767–72.

    Article  PubMed  Google Scholar 

  36. Gómez-Benlloch A, Montesel A, Pareja-Aricò L, Mingo-Botín D, Michael R, Barraquer RI, Alió J. Causes of corneal transplant failure: a multicentric study. Acta Ophthalmol. 2021;99(6):e922–8.

    Article  PubMed  Google Scholar 

  37. Szkodny D, Wróblewska-Czajka E, Wylęgała A, Nandzik M, Wylęgała E. Incidence of complications related to corneal graft in a group of 758 patients. J Clin Med 2022, 12(1).

  38. Zare M, Javadi MA, Einollahi B, Karimian F, Rafie AR, Feizi S, Azimzadeh A. Changing indications and surgical techniques for corneal transplantation between 2004 and 2009 at a tertiary referral center. Middle East Afr J Ophthalmol. 2012;19(3):323–9.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Shimmura S, Tsubota K. Deep anterior lamellar keratoplasty. Curr Opin Ophthalmol. 2006;17(4):349–55.

    Article  PubMed  Google Scholar 

  40. Gao H, Huang T, Pan Z, Wu J, Xu J, Hong J, Chen W, Wu H, Kang Q, Zhu L, et al. Survey report on keratoplasty in China: A 5-year review from 2014 to 2018. PLoS ONE. 2020;15(10):e0239939.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Qu LJ, Xie LX. Changing indications for lamellar keratoplasty in Shandong, 1993–2008. Chin Med J (Engl). 2010;123(22):3268–71.

    PubMed  Google Scholar 

  42. Williams KA, Esterman AJ, Bartlett C, Holland H, Hornsby NB, Coster DJ. How effective is penetrating corneal transplantation? Factors influencing long-term outcome in multivariate analysis. Transplantation. 2006;81(6):896–901.

    Article  PubMed  Google Scholar 

  43. Barraquer RI, Pareja-Aricò L, Gómez-Benlloch A, Michael R. Risk factors for graft failure after penetrating keratoplasty. Med (Baltim). 2019;98(17):e15274.

    Article  Google Scholar 

  44. Williams KA, Lowe M, Bartlett C, Kelly TL, Coster DJ. Risk factors for human corneal graft failure within the Australian corneal graft registry. Transplantation. 2008;86(12):1720–4.

    Article  PubMed  Google Scholar 

  45. Stulting RD, Sugar A, Beck R, Belin M, Dontchev M, Feder RS, Gal RL, Holland EJ, Kollman C, Mannis MJ, et al. Effect of donor and recipient factors on corneal graft rejection. Cornea. 2012;31(10):1141–7.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Sibley D, Hopkinson CL, Tuft SJ, Kaye SB, Larkin DFP. Differential effects of primary disease and corneal vascularisation on corneal transplant rejection and survival. Br J Ophthalmol. 2020;104(5):729–34.

    Article  PubMed  Google Scholar 

  47. Armitage WJ, Goodchild C, Griffin MD, Gunn DJ, Hjortdal J, Lohan P, Murphy CC, Pleyer U, Ritter T, Tole DM, et al. High-risk corneal transplantation: recent developments and future possibilities. Transplantation. 2019;103(12):2468–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Raj A, Dhasmana R, Bahadur H. Factors associated with surface epithelial keratopathy after optical penetrating keratoplasty. J Curr Ophthalmol. 2017;29(2):108–15.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Feizi S, Javadi F, Javadi MA. Graft epithelial defects after deep anterior lamellar keratoplasty. Cornea. 2014;33(11):1145–8.

    Article  PubMed  Google Scholar 

  50. Constantinou M, Jhanji V, Vajpayee RB. Clinical and Microbiological profile of post-penetrating keratoplasty infectious keratitis in failed and clear grafts. Am J Ophthalmol. 2013;155(2):233–e237232.

    Article  PubMed  Google Scholar 

  51. Wright TM, Afshari NA. Microbial keratitis following corneal transplantation. Am J Ophthalmol. 2006;142(6):1061–2.

    Article  PubMed  Google Scholar 

  52. Feizi S, Javadi MA, Kanavi MR, Javadi F. Effect of donor graft quality on clinical outcomes after deep anterior lamellar keratoplasty. Cornea. 2014;33(8):795–800.

    Article  PubMed  Google Scholar 

  53. Song A, Deshmukh R, Lin H, Ang M, Mehta JS, Chodosh J, Said DG, Dua HS, Ting DSJ. Post-keratoplasty infectious keratitis: epidemiology, risk factors, management, and outcomes. Front Med (Lausanne). 2021;8:707242.

    Article  PubMed  Google Scholar 

  54. Gao Y, Li C, Bu P, Zhang L, Bouchard CS. Infectious interface keratitis (IIK) following lamellar keratoplasty: A literature review. Ocul Surf. 2019;17(4):635–43.

    Article  PubMed  Google Scholar 

  55. Vajpayee RB, Sharma N, Sinha R, Agarwal T, Singhvi A. Infectious keratitis following keratoplasty. Surv Ophthalmol. 2007;52(1):1–12.

    Article  PubMed  Google Scholar 

  56. Davila JR, Mian SI. Infectious keratitis after keratoplasty. Curr Opin Ophthalmol. 2016;27(4):358–66.

    Article  PubMed  Google Scholar 

  57. Sharma N, Kumar C, Mannan R, Titiyal JS, Vajpayee RB. Surgical technique of deep anterior lamellar keratoplasty in descemetoceles. Cornea. 2010;29(12):1448–51.

    Article  PubMed  Google Scholar 

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Acknowledgements

Not applicable.

Funding

The research received funding through grants 2019YFC0840708 from the National Key R&D Program of China, 2024C03206 from the Zhejiang Province Leading Geese Plan, Y20211005 from the Science and Technology Plan Project of Wenzhou Municipality, TJYXZDXK-037 A from the Tianjin Key Medical Discipline (Specialty) Construction Project and ZYYD2024CG16 from the Centralized Guided Local Science and Technology Development Funds Project of China.

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Author notes

  1. Chenxi Wang and He Xie contributed equally as co-first authors.

Authors and Affiliations

  1. Department of Ophthalmology, National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China

    Chenxi Wang, He Xie, Binjia Sun, Kexin Tang, Haiou Wang, Zelin Zhao, Qinxiang Zheng, Ruifen Wei, Minye Wang & Wei Chen

  2. Department of Ophthalmology, Ningbo Eye Institute, Ningbo Eye Hospital, Wenzhou Medical University, Ningbo, Zhejiang, China

    Qinxiang Zheng, Feng Wen, Wei Qiang & Wei Chen

  3. Department of Ophthalmology, Xi’an No. 1 Hospital, No. 30, Fen Alley, South Street, Xi’an, Shaanxi, China

    Jie Wu & Yan Cheng

  4. Center of Ophthalmology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China

    Chenxi Wang

  5. Department of Ophthalmology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China

    Qi Zhang

  6. Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China

    Baihua Chen

  7. Department of Ophthalmology, The Third People’s Hospital of Dalian & Dalian Municipal Eye Hospital, Dalian, Liaoning, China

    He Dong

  8. Department of Cornea, Shanxi Eye Hospital, Taiyuan, Shanxi, China

    Jizhong Yang & Yuping Han

  9. Department of Ophthalmology, Second People’s Hospital of Yunnan Province, The Affiliated Hospital of Yunnan University, Kunming, Yunnan, China

    Hai Liu

  10. Department of Ophthalmology, Jiangxi Province Division of National Clinical Research Center of Ocular Disease, The Affiliated eye hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China

    Tao Sun & Qi Xie

  11. Department of Ophthalmology, The Affiliated Eye Hospital, Nanjing Medical University, Nanjing, Jiangsu, China

    Jinsong Xue & Yingnan Xu

  12. Corneal & Refractive surgery center, Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute, School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China

    Shaozhen Zhao & Hui Liu

  13. Department of Ophthalmology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China

    Limin Chen

  14. Department of Ophthalmology, Sichuan Academy of Medical Sciences Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China

    Zhirong Liu & Man Yu

  15. Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China

    Yanning Yang & Linying Huang

  16. Department of Ophthalmology, Ningxia Eye Hospital, People’s Hospital of Ningxia Hui Autonomous Region, Third Clinical Medical College of Ningxia Medical University, Ningxia Hui Autonomous Region, Yinchuan, China

    Xunlun Sheng & Huiping Li

  17. Department of Ophthalmology, Lanzhou University Second Hospital, Lanzhou, Gansu, China

    Pengcheng Wu

  18. First People’s Hospital of Aksu, Aksu, Xinjiang, China

    Gang Chen

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  1. Chenxi Wang
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  2. He Xie
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  34. Yan Cheng
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  35. Wei Chen
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Contributions

WC, YC: concept and design, critical revision and final approval of the article; CW, HX: concept and design, analysis and interpretation, writing the article; BS, KT, HW, ZZ, QZ: data acquisition and critical revision of manuscript; JW, QZ, BC, HD, JY, HL, FW, TS, JX, SZ, LC, ZL, YY, XS, PW, YH, WQ, QX, YX, HL, MY, LH, HL, RW, MW, GC: provision of materials, patients or resources and data collection. All authors reviewed the manuscript.

Corresponding authors

Correspondence to Yan Cheng or Wei Chen.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the ethics committee of Eye Hospital, Wenzhou Medical University, Zhejiang, China (approval no.2020-217-K-197-01). Otherwise, the study protocol was approved by the ethics committee at each participating centre, the study used data collected from inpatient medical records while maintaining patient anonymity, and the institutional review board approved waiver of patient informed consent.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Electronic supplementary material

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Supplementary Material 1: Fig. 1. Geographical distribution map of the centers in study.

12886_2025_4010_MOESM2_ESM.jpeg

Supplementary Material 2: Fig. 2 Timing of 90-day readmission by discharge day in patients readmitted after index hospitalization related to deep anterior lamellar keratoplasty.

12886_2025_4010_MOESM3_ESM.jpeg

Supplementary Material 3: Fig. 3. The anterior segment photographed images of patients at readmission. Legends: a. bacterial keratitis; b.fungal keratitis; c.viral keratitis; d.mixed infectious keratitis; e.corneal epithelial defect; f.recurrence of marginal corneal ulcer; g.corneal trauma; h.corneal descemet membrane detachment; i.unknown graft opacity

Supplementary Material 4 Table 1. the number of keratoplasty in centers enrolled in the study(eyes)

12886_2025_4010_MOESM5_ESM.docx

Supplementary Material 5 Table 2. The specific disease classification of indications for deep anterior lamellar keratoplasty

12886_2025_4010_MOESM6_ESM.jpeg

Supplementary Material 6: Fig. 4 The proportions of readmission causes among patients with different indications for deep lamellar keratoplasty (%).

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Wang, C., Xie, H., Sun, B. et al. Clinical characteristics and risk factors for readmission after deep anterior lamellar keratoplasty: a nationwide, cross-sectional, multicenter study. BMC Ophthalmol 25, 193 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12886-025-04010-1

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Keywords

BMC Ophthalmology

ISSN: 1471-2415

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