Elsevier

Ophthalmology

Volume 120, Issue 2, February 2013, Pages 246-251
Ophthalmology

Original article
Descemet's Stripping Automated Endothelial Keratoplasty: Three-Year Graft and Endothelial Cell Survival Compared with Penetrating Keratoplasty

Presented at: American Academy of Ophthalmology Annual Meeting, October 2011, Orlando, Florida.
https://doi.org/10.1016/j.ophtha.2012.08.007Get rights and content

Purpose

To assess 3-year outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) in comparison with penetrating keratoplasty (PKP) from the Cornea Donor Study (CDS).

Design

Prospective, multicenter, nonrandomized clinical trial.

Participants

A total of 173 subjects undergoing DSAEK for a moderate risk condition (principally Fuchs' dystrophy or pseudophakic corneal edema) compared with 1101 subjects undergoing PKP from the CDS.

Methods

The DSAEK procedures were performed by 2 experienced surgeons using the same donor and similar recipient criteria as for the CDS PKP procedures, performed by 68 surgeons. Graft success was assessed by Kaplan-Meier survival analysis. Central endothelial cell density (ECD) was determined from baseline donor and postoperative central endothelial images by the reading center used in the CDS Specular Microscopy Ancillary Study.

Main Outcome Measures

Graft clarity and ECD.

Results

The donor and recipient demographics were comparable in the DSAEK and PKP groups, except that the proportion of Fuchs' dystrophy cases was higher in the DSAEK cohort. The 3-year survival rate did not differ significantly between DSAEK and PKP procedures performed for either Fuchs' dystrophy (96% for both; P = 0.81) or non-Fuchs' cases (86% vs. 84%, respectively; P = 0.41). Principal causes of graft failure or regraft within 3 years after DSAEK and PKP were immunologic graft rejection (0.6% vs. 3.1%), endothelial decompensation in the absence of documented rejection (1.7% vs 2.1%), unsatisfactory visual or refractive outcome (1.7% vs. 0.5%), and infection (0% vs. 1.1%), respectively. The 3-year predicted probability of a rejection episode was 9% with DSAEK versus 20% with PKP (P = 0.0005). The median 3-year cell loss for DSAEK and PKP was 46% and 51%, respectively (P = 0.33), in Fuchs' dystrophy cases and 59% and 61%, respectively (P = 0.70), in the non-Fuchs' cases. At 3 years, use of a smaller DSAEK insertion incision was associated with significantly higher cell loss (60% vs. 33% for 3.2- and 5.0-mm incisions, respectively; P = 0.0007), but not with a significant difference in graft survival (P = 0.45).

Conclusions

The graft success rate and endothelial cell loss were comparable at 3 years for DSAEK and PKP procedures. A 5-mm DSAEK incision width was associated with significantly less cell loss than a 3.2-mm incision.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Study Design

In this prospective, interventional study, subjects were treated with DSAEK at Gorovoy Eye Specialists (Fort Myers, FL) or the Price Vision Group (Indianapolis, IN) between June 2006 and September 2007. The University Hospitals Case Medical Center (Cleveland, OH) Institutional Review Board approved the study, and written informed consent was provided by all participants. Originally, this study was designed with a 1-year follow-up,3 and subsequently subjects were invited to participate in a

Recipient and Donor Characteristics

A total of 173 DSAEK eyes (173 subjects) were enrolled in the initial study. The mean age was 72±11 years, 60% were female, and 98% were white. The demographics of the DSAEK cohort were similar to the PKP cohort in the SMAS, as previously described,3 but the DSAEK group had a significantly higher incidence of Fuchs' dystrophy (85% vs. 64%; P<0.0001) and a lower incidence of pseudophakic or aphakic corneal edema (13% vs. 32%). The donor criteria in this study were the same as in the CDS, and

Discussion

The key finding in this study was that 3-year graft survival and endothelial cell loss were comparable for DSAEK and PKP with essentially the same donor and recipient characteristics and ECD determined by the same reading center. Compared with the PKP cohort, the DSAEK cohort experienced more cell loss in the first year, which was probably associated with surgical manipulation and trauma to the graft. In subsequent years, however, the DSAEK cohort experienced a lower rate of cell loss than the

References (15)

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Cited by (0)

Manuscript no. 2012-733.

Financial Disclosure(s): The author(s) have made the following disclosure(s):

Marianne O. Price and Francis W. Price, Jr.: Financial support—Moria.

Supported by the National Eye Institute, Bethesda, Maryland (grant nos.: EY15145 and EY12728); the Eye Bank Association of America, Washington, DC; Vision Share, Apex, North Carolina; the Cornea Research Foundation of America, Indianapolis, Indiana; Research to Prevent Blindness, Inc, New York, New York; and Ohio Lions Eye Research Foundation, Grove City, Ohio.

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