Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty.

PURPOSE: To report the rate of graft dislocation, surgical anatomic success, and postsurgical complications associated with Descemet stripping automated endothelial keratoplasty (DSAEK) after previous primary failed penetrating keratoplasty (PK). METHODS: Institutional review board-approved, single-center, retrospective chart review study of 30 eyes of 30 patients with prior failed PK who underwent DSAEK with a minimum of 3 months follow-up. Primary outcomes measured included rates of anatomic success and failure, postoperative complications, lenticle size, visual acuity, intraocular pressure change, and a report of external factors that may affect success. RESULTS: Thirty eyes of 30 patients were identified. The primary dislocation rate was 16.7%. Five primary DSAEKs detached; 1 was successfully rebubbled in the office, 2 had repeat successful DSAEKs, and 2 failed on a second attempt and had a subsequent PK. Despite successful anatomic attachment, 1 eye had primary graft failure, 3 that cleared initially failed within 6 months, and 1 that successfully cleared had subsequent graft rejection resulting in failure at 6 months. The 2 eyes requiring PK were excluded from the visual outcomes analysis, leaving 28 eyes with successfully attached lenticles. At 3 months postoperatively, of the 28 eyes, 19 showed an improvement in visual acuity, 6 had no change in vision from preoperative data, and 1 had worsening of vision (anatomic attachment but endothelial failure). Two of the 28 eyes had no data at that time point. CONCLUSIONS: DSAEK eyes after failed PK demonstrated improved vision with a low complication rate in a majority of patients. The graft dislocation rate and postoperative complications rates are comparable with the primary DSAEK dislocation rates in our own published series and in the literature.

Graft rejection following descemet stripping automated endothelial keratoplasty: features, risk factors, and outcomes.

PURPOSE: 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). DESIGN: 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.