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A comparison of endothelial and penetrating keratoplasty outcomes following failed penetrating keratoplasty: a registry study
  1. Miriam C Keane,
  2. Rachel A Galettis,
  3. Richard A D Mills,
  4. Douglas J Coster,
  5. Keryn A Williams
  6. for Contributors to the Australian Corneal Graft Registry
  1. Department of Ophthalmology, Flinders University, Adelaide, South Australia, Australia
  1. Correspondence to Professor Keryn A Williams, Department of Ophthalmology, Flinders University, Flinders Medical Centre, Bedford Park, SA 5042, Australia; keryn.williams{at}


Purpose To compare graft survival and visual outcomes for endothelial keratoplasty (EK) after a first penetrating keratoplasty (PK), with outcomes of repeat PK after a first PK.

Methods 400 eyes with a second graft (65 EKs, 335 PKs) performed after failure of a primary PK were identified through the Australian Corneal Graft Registry, a national prospectively followed cohort. Grafts were performed after January 2008 (follow-up of the second graft extending to 6.75 years maximum). Kaplan–Meier graft survival plots were constructed and Cox proportional hazards regression was used to identify independent risk factors for graft failure. Best-corrected Snellen visual acuity (BCVA) at last follow-up was compared with pregraft acuity.

Results Poor Kaplan–Meier graft survival was observed for PK-EK compared with PK-PK (log-rank=29.66, p<0.001). Variables retained in multivariate analysis as significantly influencing survival of the second graft included graft type (PK-EK or PK-PK, p<0.001), length of survival of the previous PK (global p=0.011), graft era (global p=0.018), occurrence of rejection in the second graft (p=0.005) and a history of raised intraocular pressure at any time (p=0.048), but not indication for the first graft. BCVA improved in the majority of surviving grafts and attainment of 6/12 vision was similar for both PK-EK and PK-PK groups.

Conclusions Our registry findings suggest that repeat PK may deliver a better outcome in terms of graft survival than EK after a failed PK that was performed initially for keratoconus or pseudophakic bullous keratopathy. For surviving grafts, visual outcomes appeared equivalent across groups.

  • Cornea

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  • Contributors MCK: acquisition of data, analysis and interpretation of data, drafting of manuscript. RAG: acquisition of data. RADM: revision of manuscript. DJC: critical revision of the manuscript on multiple occasions. KAW: study concept and design, interpretation of data, drafting and critical revision of manuscript. Contributors to the ACGR: voluntary provision of data.

  • Funding Supported by the Australian Government Organ and Tissue Donation Authority (DonateLife). KAW is supported by the National Health and Medical Research Council of Australia.

  • Competing interests None declared.

  • Ethics approval Approved by the Institutional Clinical Ethics Review Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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