Graft Survival Rate Post-Penetrating Keratoplasty Decreases by Nearly Half at 20 Years Postoperatively

TRUJILLO, PERU – APRIL 20: A surgeon works on the eye of Reis-Buckler syndrome patient Diana, aged 17, during surgery onboard the Orbis Flying Eye Hospital on April 20, 2018 in Trujillo, Peru. Reis-Buckler corneal dystrophy is a rare genetic condition which causes the Bowman’s layer of the cornea to disintegrate. Diana’s mother Rosa has the same syndrome and has struggled with sight loss since the age of nine. After suffering with the condition since the age of three, Diana was chosen for a penetrating keratoplasty procedure (cornea transplant) during a programme run by Orbis, the ophthalmic training organisation. Founded in 1982 by ophthalmologist David Paton, Orbis trains eyecare teams across Africa, Asia and Latin America to improve the standard of eyecare in the region. As well as working in local hospitals, the charity also has a self-sufficient surgical unit on the Orbis Flying Eye Hospital, a converted McDonald-Douglas MD10 aircraft. (Photo by Leon Neal/Getty Images)
The study also shows allograft rejection and late endothelial failure’s roles in graft failures.

A 20-year review of penetrating keratoplasty in Asian eyes found that graft survival decreased significantly over time, falling from 91% at 1 year to 44% at 20 years follow-up, according to a study published online October 27, 2020 in American Journal of Ophthalmology.

Researchers conducted a prospective cohort study based on records from the (also prospective) Singapore Corneal Transplant Study’s computerized database. They sought to understand the long-term optical, therapeutic, and tectonic forms of penetrating keratoplasty (PK) in this patient population.

PK was performed at the Singapore National Eye Centre between January 1991 to December 2010, with researchers reviewing records of preoperative, intraoperative, and postoperative patient data and donor data. Primary grafts were the only graft type included in the study. 

They analyzed the following: patient demographics, donor source, grafting indications, complications, graft survival rate, and reasons for graft failure. They studied the results of 1206 primary PKs. The patients’ mean age was 55 years. 

Overall corneal graft survival was 91%, 66.8%, 55.4%, 52% and 44% at 1, 5, 10, 15 and 20 years, respectively. Pseudophakic bullous keratopathy (PBK), post infectious corneal scarring/thinning, and keratoconus were the most common diagnoses for optical grafts. Optical grafts had significantly better graft survival when compared with therapeutic and tectonic grafts at all time points. 

“Multivariate analysis suggests that a younger donor age and higher donor endothelial cell count are associated with better long-term graft survival for optical grafts,” according to investigators. “Irreversible allograft rejection and late endothelial failure accounted for more than 60% of graft failures.”


Anshu A, Li L, Htoon H, et al. Long-term review of Penetrating Keratoplasty: A 20-year review in Asian eyes. American Journal of Ophthalmology. Published online November 1, 2020. doi: 10.1016/j.ajo.2020.10.014.