Repeat keratoplasty in failed Descemet stripping automated endothelial keratoplasty

Abstract

Purpose:To evaluate the clinical factors associated with repeat Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty (PKP) in cases of failed DSAEK.Methods:Retrospective observational study of cases with failed DSAEK admitted to our center for a repeat keratoplasty over 5 years (January 2013–Decemeber 2017) was undertaken. Demographic and perioperative details of all cases and type of repeat keratoplasty were recorded. Logistic regression analysis was performed to analyze the factors affecting the type of repeat keratoplasty.Results:A total of 94 eyes with failed DSAEK were evaluated. Repeat DSAEK was performed in 66% and PKP in 34% of cases. Significantly increased odds for requiring PKP were observed in association with stromal scarring [odds ratio (OR) = 2.9, P = 0.018)], trainee surgeons (OR = 4.05, P = 0.008), intraoperative complications (OR = 4.58, P = 0.003), scleral fixated intraocular lens or anterior chamber intraocular lens in situ (OR = 33.8, P < 0.001), secondary glaucoma (OR = 3.02, P = 0.015), peripheral anterior synechiae (OR = 8.6, P < 0.001), preoperative corneal thickness (OR = 1.01, P < 0001), time to primary surgery (OR = 1.03, P = 0.03), post-DSAEK host thickness (OR = 1.01, P < 0.001), and time interval from graft failure to regraft (OR = 1.18, P < 0.001). All eyes with congenital hereditary endothelial dystrophy, bee-sting-induced corneal decompensation, Axenfeld-Rieger syndrome, and multiple failed grafts underwent secondary PKP. All cases (nine eyes) that required surgical intervention for secondary glaucoma underwent secondary PKP (P < 0.001).Conclusion:Repeat DSAEK is feasible in up to two-third of cases of failed DSAEK. A PKP is required in one-third of cases, and various preoperative, intraoperative and postoperative factors are associated with unsuitability for repeat DSAEK.

Comparison of glaucoma therapy escalation after penetrating keratoplasty to descemet stripping automated endothelial keratoplasty for the treatment of pseudophakic bullous keratopathy: A cohort study

“…An Indian study that enrolled a large sample of patients reported that glaucoma was the primary factor in eyes that underwent repeat DSAEK. [ 25 ] A long-term review of graft failure 20 years after PK also noted late endothelial decompensation as the main reason for poor results in PBK. [ 26 ] Pl remove this sentence Thus, the issue of GTE requires attention to increase success with keratoplasty for managing PBK.…”

Preserving posterior capsular integrity in post-endothelial keratoplasty posterior capsular opacification

“…A repeat graft is one of the most frequent indications of keratoplasty, and a re-graft may be required in 5% to 10.5% of cases after EK. [ 11 12 ] A defective posterior capsule increases the incidence of intraoperative complications during a repeat keratoplasty, including vitreous prolapse, IOL dislocation, and extrusion which adversely impacts graft survival. In addition, a loss of posterior capsule integrity will lead to difficulties in ensuring adequate air tamponade in anterior chamber during a repeat surgery, with high likelihood of migration of air posteriorly and subsequent graft dislocation.…”

Secondary Endothelial Keratoplasty—A Narrative Review of the Outcomes of Secondary Corneal Endothelial Allografts

“…Ten studies (n = 403 eyes) analyzed the outcomes of repeat DSEK (re-DSEK). [61][62][63][64][65][66][67][68][69][70] The 2 main indications for re-DSEK were failed primary DSEK graft and poor visual performance after primary DSEK. Prior aqueous shunt surgery, donor graft CEC density, and at least 1 documented postoperative rejection episode were the main factors associated with the need for DSEK graft exchange after primary DSEK in a multivariable model.…”

“…63 Reported visual outcomes seem to be similar to those achieved for primary DSEK surgery, 67 with mean CDVA after re-DSEK ranging from 0.50 to 0.18 logMAR (Snellen equivalent 20/30-20/63). 63,64,66,70 Besides, maximal postoperative CDVA after re-DSEK reported rates of eyes reaching CDVA ≥20/40 following re-DSEK ranges from 20% to 100%. [62][63][64] If studies with ≤2 eyes were excluded from this analysis, then the proportion of eyes reaching CDVA ≥20/40 would be 20%-82%, and no studies observed eyes reaching CDVA ≥20/25.…”

“…61 Regraft failure rates were reported in 8 studies (n = 245 eyes), ranging from 0% to 20% (follow-up times ranging from 6 to 27 mo). 61,[64][65][66][67]70 A prospective longterm analysis performed by the Netherlands Organ Transplantation Registry found that regraft survival is lower compared with primary graft survival. 67 These findings are similar to those reported in a retrospective study in which re-DSEK grafts were reported to be at increased risk of rejection and graft failure compared with primary DSEK eyes (Moura-Coelho et al, personal communication, 2019).…”