title: Descemet's stripping automated endothelial keratoplasty: three-year graft and endothelial cell survival compared with penetrating keratoplasty.
abstract: OBJECTIVE
  To assess 3-year outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) in comparison with penetrating keratoplasty (PKP) from the Cornea Donor Study (CDS).
  
  
  METHODS
  Prospective, multicenter, nonrandomized clinical trial.
  
  
  METHODS
  A total of 173 subjects undergoing DSAEK for a moderate risk condition (principally Fuchs' dystrophy or pseudophakic corneal edema) compared with 1101 subjects undergoing PKP from the CDS.
  
  
  METHODS
  The DSAEK procedures were performed by 2 experienced surgeons using the same donor and similar recipient criteria as for the CDS PKP procedures, performed by 68 surgeons. Graft success was assessed by Kaplan-Meier survival analysis. Central endothelial cell density (ECD) was determined from baseline donor and postoperative central endothelial images by the reading center used in the CDS Specular Microscopy Ancillary Study.
  
  
  METHODS
  Graft clarity and ECD.
  
  
  RESULTS
  The donor and recipient demographics were comparable in the DSAEK and PKP groups, except that the proportion of Fuchs' dystrophy cases was higher in the DSAEK cohort. The 3-year survival rate did not differ significantly between DSAEK and PKP procedures performed for either Fuchs' dystrophy (96% for both; P = 0.81) or non-Fuchs' cases (86% vs. 84%, respectively; P = 0.41). Principal causes of graft failure or regraft within 3 years after DSAEK and PKP were immunologic graft rejection (0.6% vs. 3.1%), endothelial decompensation in the absence of documented rejection (1.7% vs 2.1%), unsatisfactory visual or refractive outcome (1.7% vs. 0.5%), and infection (0% vs. 1.1%), respectively. The 3-year predicted probability of a rejection episode was 9% with DSAEK versus 20% with PKP (P = 0.0005). The median 3-year cell loss for DSAEK and PKP was 46% and 51%, respectively (P = 0.33), in Fuchs' dystrophy cases and 59% and 61%, respectively (P = 0.70), in the non-Fuchs' cases. At 3 years, use of a smaller DSAEK insertion incision was associated with significantly higher cell loss (60% vs. 33% for 3.2- and 5.0-mm incisions, respectively; P = 0.0007), but not with a significant difference in graft survival (P = 0.45).
  
  
  CONCLUSIONS
  The graft success rate and endothelial cell loss were comparable at 3 years for DSAEK and PKP procedures. A 5-mm DSAEK incision width was associated with significantly less cell loss than a 3.2-mm incision.
authors.affiliation: Cornea Research Foundation of America, Indianapolis, Indiana 46260, USA. mprice@cornea.org
authors.forename: Marianne O
authors.initials: MO
authors.lastname: Price
authors.forename: Mark
authors.initials: M
authors.lastname: Gorovoy
authors.forename: Francis W
authors.initials: FW
authors.lastname: Price
authors.forename: Beth A
authors.initials: BA
authors.lastname: Benetz
authors.forename: Harry J
authors.initials: HJ
authors.lastname: Menegay
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Lass
mesh_terms: D000368:Aged; D002452:Cell Count; D015715:Corneal Edema / Q000601:surgery*; D055954:Corneal Endothelial Cell Loss / Q000503:physiopathology; D057111:Descemet Stripping Endothelial Keratoplasty; D004728:Endothelium, Corneal / Q000502:physiology*; D005260:Female; D005642:Fuchs' Endothelial Dystrophy / Q000601:surgery*; D006085:Graft Survival / Q000502:physiology*; D006801:Humans; D015948:Keratoplasty, Penetrating; D008297:Male; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome