title: Graft rejection following descemet stripping automated endothelial keratoplasty: features, risk factors, and outcomes.
abstract: OBJECTIVE
  To investigate the clinical features, risk factors, and treatment outcomes following immunologic graft rejection in eyes that have undergone Descemet stripping automated endothelial keratoplasty (DSAEK).
  
  
  METHODS
  Retrospective case review.
  
  
  METHODS
  The charts for 353 DSAEK procedures performed at a single clinical practice at the New York Eye and Ear Infirmary from August 2006 to November 2010 were reviewed. Cases with at least 3 months follow-up were included. Outcome measures included rates of graft rejection, clinical findings, treatment outcomes, and risk factor analysis.
  
  
  RESULTS
  Thirty of 353 DSAEKs developed graft rejection (8.5%). Kaplan-Meier rate of rejection was 6.0% at 1 year (n = 175), 14.0% at 2 years (n = 79), and 22.0% at 3 years (n = 39). Rejection episodes occurred between 0.8 and 34 months. Clinical findings included anterior chamber cells, keratic precipitates, endothelial rejection line, and host-donor interface vascularization. Risk factors for development of graft rejection were cessation of postoperative steroid (hazard ratio 5.49, P < .0001) and black race (hazard ratio 2.71, P = .02). Recipient age, sex, surgical indication, glaucoma, postoperative steroid response, corneal neovascularization or peripheral anterior synechiae, graft size, prior keratoplasty in fellow eye, and concurrent or subsequent procedures were not associated with graft rejection. Twenty-two out of 30 rejection episodes (73.3%) resolved with steroid treatment.
  
  
  CONCLUSIONS
  Graft rejection is an important complication following DSAEK. In contrast to penetrating keratoplasty, rejection following DSAEK is almost exclusively endothelial. Among risk factors traditionally associated with graft rejection, cessation of topical steroids was most significant. Prompt recognition and treatment of DSAEK rejection can lead to favorable outcomes.
authors.affiliation: Department of Ophthalmology, The New York Eye and Ear Infirmary, New York, 10003, USA. ewu@nyee.edu
authors.forename: Elaine I
authors.initials: EI
authors.lastname: Wu
authors.forename: David C
authors.initials: DC
authors.lastname: Ritterband
authors.forename: Guopei
authors.initials: G
authors.lastname: Yu
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Shields
authors.forename: John A
authors.initials: JA
authors.lastname: Seedor
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057111:Descemet Stripping Endothelial Keratoplasty; D004728:Endothelium, Corneal / Q000473:pathology*; D005260:Female; D005500:Follow-Up Studies; D005642:Fuchs' Endothelial Dystrophy / Q000601:surgery; D005938:Glucocorticoids / Q000627:therapeutic use; D006084:Graft Rejection / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005938:Glucocorticoids