Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty: survival, rejection risk, and visual outcome.
OBJECTIVE
Descemet stripping automated endothelial keratoplasty (DSAEK) for isolated endothelial dysfunction has become the preferred surgical option for many corneal surgeons. However, there are limited large-scale reports on DSAEK survival and clinical variables affecting the risk of rejection and failure after failed penetrating keratoplasty (PK).


OBJECTIVE
To report the survival, risk factors for graft rejection and failure, and visual outcome of DSAEK after failed PK.


METHODS
A multicenter retrospective interventional case series included patients recruited from 6 tertiary referral surgical centers: 3 in the United States, 2 in Europe, and 1 in Asia. A total of 246 consecutive eyes (246 patients) that underwent DSAEK after failed PK, with a minimum follow-up period of 1 month, was included. Data comprising demographic details, preoperative and postoperative risk factors, time to rejection, time to failure, and corrected distance visual acuity were collected.


METHODS
Cumulative probability of graft survival, hazard ratio estimates for survival, and corrected distance visual acuity were determined.


RESULTS
The mean (SD) recipient age was 63.2 (16.6) years and the median follow-up period was 17 months (interquartile range, 6-30 months). One-third of the grafts (n = 82) had follow-up data for more than 2 years; 18.3% had more than 1 failed PK before DSAEK. In total, 19.1% (47 of 246) of DSAEK grafts failed. The cumulative probability of DSAEK survival after a failed PK was 0.89 (95% CI, 0.84-0.92), 0.74 (95% CI, 0.64-0.81), and 0.47 (95% CI, 0.29-0.61) at 1 year, 3 years, and 5 years, respectively. Based on multivariate analysis, significant preoperative risk factors for failure were young recipient age (hazard ratio [HR], 5.18 [95% CI, 1.57-17.18]), previous tube filtration surgery (HR, 5.23 [95% CI, 1.47-7.33]), and rejection episodes before PK failure (HR, 3.28 [95% CI, 1.47-7.33]); single-surgeon centers had a protective effect. Any rejection episode prior to PK failure was a significant predictor of post-DSAEK rejection, which in turn was a significant predictor of DSAEK failure. After a median follow-up of 17 months, 33.3% of the grafts achieved 0.3 or greater logMAR (20/40) corrected distance visual acuity.


CONCLUSIONS
Descemet stripping automated endothelial keratoplasty after failed PK combines greater wound stability and reduced suture-related complications, with visual outcomes and graft survival rates comparable to those of a second PK.
Department of Corneal Surgery, Moorfields Eye Hospital, London, England.
Danny
D
Mitry
Department of Corneal Surgery, Moorfields Eye Hospital, London, England.
Maninder
M
Bhogal
Department of Corneal Surgery, Birmingham Heartlands Hospital, Heart of England National Health Service Foundation Trust, Birmingham, England.
Amit K
AK
Patel
Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
Bryan S
BS
Lee
Department of Corneal Surgery, Singapore National Eye Centre, Singapore.
Shu Ming
SM
Chai
Cornea Research Foundation of America, Indianapolis, Indiana.
Marianne O
MO
Price
Price Vision Group, Indianapolis, Indiana.
Francis W
FW
Price
Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
Albert S
AS
Jun
Jules Stein Eye Institute, University of California, Los Angeles.
Anthony J
AJ
Aldave
Department of Corneal Surgery, Singapore National Eye Centre, Singapore.
Jodhbir S
JS
Mehta
Department of Corneal Surgery, Villa Serena Hospital, Forli, Italy.
Massimo
M
Busin
Department of Corneal Surgery, Moorfields Eye Hospital, London, England.
Bruce D
BD
Allan
D000368:Aged; D016001:Confidence Intervals; D003316:Corneal Diseases / Q000175:diagnosis / Q000601:surgery*; D057111:Descemet Stripping Endothelial Keratoplasty / Q000379:methods*; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D015948:Keratoplasty, Penetrating / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D017211:Treatment Failure; D016896:Treatment Outcome; D014792:Visual Acuity / Q000502:physiology*