Elsevier

Ophthalmology

Volume 119, Issue 1, January 2012, Pages 90-94
Ophthalmology

Original article
Graft Rejection After Descemet's Stripping Automated Endothelial Keratoplasty: Graft Survival and Endothelial Cell Loss

Presented at: the annual meeting of the American Academy of Ophthalmology on October 18th, 2010, Chicago, Illinois.
https://doi.org/10.1016/j.ophtha.2011.07.007Get rights and content

Purpose

To evaluate the effects of graft rejection episodes after Descemet's stripping automated endothelial keratoplasty surgery (DSAEK) on long-term endothelial cell density (ECD) decline and graft survival.

Design

Retrospective, comparative analysis of an interventional case series.

Participants

We included 615 eyes of 415 Fuchs' dystrophy patients at a single institution with ≥6 months follow-up and without comorbidities known to influence postoperative ECD. All patients were enrolled as part of an ongoing, institutional review board-approved clinical protocol for a long-term, prospective study of endothelial keratoplasty in patients with endothelial dysfunction.

Methods

Preoperative specular microscopy of donor corneal tissue was performed. Postoperative specular microscopy measurements were recorded at 6 and 12 months, and yearly thereafter. The percentages of endothelial cell loss recorded at 1, 2, 3, and 4 years were compared with the Mann–Whitney U test.

Main Outcome Measures

Percentage ECD declines were calculated at each time point from the results of the preoperative and postoperative specular microscopy. Patients with graft rejection episodes and late endothelial failure were identified. Graft rejection was defined as findings of keratic precipitates with or without corneal edema, or anterior chamber cell and flare with or without corneal edema after the initial resolution of perioperative inflammation.

Results

We identified 45 cases of graft rejection. The greatest number of rejections occurred between postoperative months 12 and 18. Eyes with a graft rejection episode had a higher median percentage decline in ECD at all time points compared with eyes without graft rejection episodes. This was statistically significant at 2 and 3 years postoperatively.

Conclusions

There is a trend toward a greater percentage of ECD loss with time in eyes experiencing graft rejection after DSAEK surgery.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Methods

All patients were enrolled as part of an ongoing, institutional review board–approved clinical protocol for a long-term prospective study of EK in patients with endothelial dysfunction. We performed 753 DSAEK procedures in eyes with Fuchs' endothelial dystrophy between September 2005 and November 2010. Among those, 639 cases (85%) were followed at our clinic for ≥6 months; 2 others did not have follow-up, but were noted to have evidence of clinical rejection during an early office visit or

Results

Table 1 highlights some demographics of patients who developed graft rejection episodes and those who did not. The groups were similar with respect to age, gender, ECD of the donor tissue, best-spectacle corrected visual acuity, and ultrasonic pachymetry. The group of patients experiencing subsequent graft rejection had a small but significant rise in preoperative intraocular pressure (P<0.001). The mean follow-up time was approximately 32 months for patients with graft rejection episodes and

Discussion

Graft rejection is a relatively common postoperative complication of DSAEK surgery that ranges from 0% to 45% in the published literature with an average rejection rate of 10%.6 Our series of patients with at least 6 month follow-up had a total graft rejection rate of 7.3% among all eyes.

Jordan et al11 recently published a large series of 598 eyes with primary Descemet's stripping with EK, evaluating the incidence, symptoms and characteristics of Descemet's stripping with EK rejection. They

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Manuscript no. 2011-20.

Financial Disclosure(s): The authors have made the following disclosures:

Mark A. Terry – Royalty payments – Bausch and Lomb Surgical for the DSAEK surgical instruments which he designed.

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