Keratoplasty Procedure Safe, Even for Those With Complex Comorbidities

Following Patients As They Receive Sight-Saving Care With Orbis In Peru
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)
Survival rates for graft and endothelial cells 10 years after DSEK are high, even for those with risk factors for graft failure.

Researchers in the United Kingdom have found that the survival rate for high-risk patients 10 years after undergoing Descemet stripping endothelial keratoplasty (DSEK) graft is 79%. Further, endothelial cell loss (ECL) was 73% at 10 years post-DSEK. For low-risk patients with Fuchs endothelial dystrophy grafts, the 10-year survival is 92%. Their findings were published in the American Journal of Ophthalmology

Having previously reported 2- and 5-year outcomes of DSEK from their center, the researchers sought to add to the limited body of published data on the long-term results of the procedure. This information can then be used to inform patients and develop service improvements.

In this retrospective clinical cohort study, investigators analyzed 356 consecutive DSEK grafts performed by 10 surgeons using a standardized protocol. Indications include Fuchs’ endothelial dystrophy (n=209), bullous keratopathy (n=88), and previous graft failure (n=39). In the study, 104 eyes (29%) had preoperative glaucoma. Cumulative graft survival of all eyes at years 1, 3, 5, and 10 were 97%, 90%, 85%, and 79%, respectively. 

The research shows that the 10-year graft survival for Fuchs’ endothelial dystrophy was 92%. The percentage ECL of all grafts were 46.6±17.3 at year 1; 54.9±18.7 at year 3; 59.6±17.4 at year 5; and 73.1±9.7 at year 10. The key risk factors for graft failure are preoperative glaucoma (HR 8.41, 95% CI, 1.30-54.5, P =.026), including previous glaucoma surgery (HR 3.63, 95% CI, 1.03-12.74, P =.04), and regrafts (HR 5.29, 95% CI, 2.02-13.89, P =.001), according to the study.

Despite a mean 10-year endothelial cell count of only 692 cells/mm2, graft survival remained high with good vision, leading the team to conclude that DSEK continues to be a viable treatment option, especially in complex eyes with comorbidity. In addition, researchers suggest that long-term topical corticosteroids and early treatment of graft rejection can reduce ECL and increase graft survival.

Limitations of this study are that not all grafts reached 10 years of follow-up or had endothelial cell density values recorded at each visit. In addition, surgeons’ learning curves can also affect graft survival, especially in the first 50 cases. Lastly, surgical protocols for the DSEK procedure are standardized at the center involved in the study, which may not occur at all centers.


Fu L, Hollick E. Long-term outcomes of descemet stripping endothelial keratoplasty: ten-year graft survival and endothelial cell loss. Am J Ophthalmol. Published August 17, 2021. doi:10.1016/j.ajo.2021.08.005