Factors associated with graft survival and endothelial cell density after Descemet's stripping automated endothelial keratoplasty

Nobuhito Ishii, Takefumi Yamaguchi, Hiroyuki Yazu, Yoshiyuki Satake, Akitoshi Yoshida, Jun Shimazaki, Nobuhito Ishii, Takefumi Yamaguchi, Hiroyuki Yazu, Yoshiyuki Satake, Akitoshi Yoshida, Jun Shimazaki

Abstract

Postoperative endothelial cell loss leads to graft failure after corneal transplantation, and is one of the important issues for long-term prognosis. The objective of this study was to identify clinical factors affecting graft survival and postoperative endothelial cell density (ECD) after Descemet's stripping automated endothelial keratoplasty (DSAEK). A total of 198 consecutive Japanese patients (225 eyes) who underwent DSAEK were analysed using Cox proportional hazard regression and multiple linear regression models. The candidate factors included recipient age; gender; diagnosis; pre-existing iris damage state, scored based on its severity; the number of previous intraocular surgeries; graft ECD; graft diameter; simultaneous cataract surgery; surgeons experience; intraoperative iris damage; postoperative rebubbling; and graft rejection. Eyes with higher pre-existing iris damage score and more number of previous intraocular surgery had a significantly higher risk of graft failure (HR = 8.53; P < 0.0001, and HR = 2.66; P = 0.026, respectively). Higher pre-existing iris damage score, lower graft ECD, and smaller graft diameter were identified as significant predisposing factors for lower postoperative ECD. The results show that iris damage status before DSAEK may be clinically useful in predicting the postoperative course. Avoiding intraoperative iris damage, especially in eyes with low ECD can change the prognosis of future DSAEK.

Figures

Figure 1. Iris damage scoring methods.
Figure 1. Iris damage scoring methods.
Iris damage (white arrows) was scored based on preoperative slit-lamp microscopy and iris photograph using infrared light as follows: 0, no iris damage; 1, iris damage limited to only one quadrant: 2, iris damage in two quadrants: 3, iris damage in three quadrants: 4, iris damage in four quadrants. Intraoperative iris damage was assessed and regarded as one of independent factors.
Figure 2. Kaplan Meier survival curves stratified…
Figure 2. Kaplan Meier survival curves stratified by iris damage score and different aetiologies.
In all subjects (a) and the subjects with LI-BK (c) PBK (d) and other aetiologies (e) there were significant differences in survival rates among the subjects with no iris damage or low iris damage score (1–2) and those with high iris damage scores (3–4). In eyes with FECD, no patient had iris damage. Others included failed graft after PKP (12 eyes) and failed DSAEK (10 eyes), chronic uveitis (6 eyes), birth injury (5 eyes), and other causes such as endotheliitis.
Figure 3. Endothelial cell loss after DSAEK…
Figure 3. Endothelial cell loss after DSAEK classified by iris damage score.
A biexponential model was fitted to the ECD classified by the iris damage score. The decrease in the ECD was greater in the group with iris damage scores of 3–4 than the groups with iris damage score of 0 and 1–2.

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