Endothelial keratoplasty has become the gold standard for treating corneal endothelial dysfunction, but long-term outcomes remain largely unknown. A new study recently presented at the ARVO 2021 virtual meeting this week reports Descemet stripping endothelial keratoplasty (DSEK) provided superior long-term visual rehabilitation and had a 15-year survival rate comparable to penetrating keratoplasty when performed for similar indications.

The research team, from the Cornea Research Foundation and the Price Vision Group of Indiana, also found that DSEK failures occurring within the first year were mostly associated with the learning curve at a time when techniques and instrumentation were still being developed and refined.

The retrospective, observational study assessed 15 years of postoperative outcomes in 360 DSEK cases performed between 2003 and 2005 at a single center. The transplant indications included Fuchs’ dystrophy (301, 84%), bullous keratopathy (34, 9%) and previous keratoplasty failure (25, 7%). The investigation’s main outcomes were graft survival and immunologic rejection rates determined by Kaplan-Meier and proportional hazards analysis, central corneal thickness (CCT) measured with ultrasonic pachymetry and best spectacle-corrected visual acuity assessed with a Snellen chart.

At 15 years, 50 grafts had failed or been replaced (14%) and 136 (38%) were in patients who had died. Only 55 of the remaining 174 grafts (32%) were available for examination.

The 15-year graft failure/replacement rate was 22%, taking loss to follow-up into consideration, the researchers noted.

Within the first year, 15 grafts were replaced due to early failure to clear (nine cases) or unsatisfactory vision associated with excessive graft thickness or wrinkles (six). Additionally, 35 experienced late endothelial failure (11 after clinically evident immunologic rejection and 24 without evidence of rejection). Glaucoma filtration surgery, present in 34 eyes (9%), was tied to a four-times greater risk of graft failure.

Also of note: CCT remained stable at 650μm to 660μm from six months to 15 years. Additionally, the BCVA among all examined eyes was 20/40 from three to 12 months and 20/30 from two to 15 years.