Secondary Graft Failure and Repeat Endothelial Keratoplasty after Descemet's Stripping Automated Endothelial Keratoplasty

Objective To identify the causes of secondary graft failure after Descemet's stripping automated endothelial keratoplasty (DSAEK) and to evaluate the clinical outcomes of repeat endothelial keratoplasty (REK) in this patient population. Design Retrospective case series. Participants Patients of a private practice Price Vision Group in Indianapolis, Indiana. Methods An initial consecutive series of primary DSAEK procedures performed by a single surgeon between October 2004 and December 2008 was reviewed to identify reasons for and outcomes of REK. Main Outcome Measures Visual acuity and causes of secondary graft failure. Results In a consecutive series of 1050 primary DSAEK procedures, REK for secondary graft failure was performed in 37 eyes (3.5%). The most common reason for REK in this group was unsatisfactory visual acuity relative to the anticipated vision potential (n = 28/37; 76%). Unsatisfactory visual acuity was associated with abnormalities of donor tissue within the pupillary area, including wrinkles or folds, irregular graft thickness, and opacity in the interface. In the 28 eyes with unacceptable visual acuity after initial DSAEK, the median best spectacle-corrected visual acuity (BSCVA) before and after REK was 20/60 (range, 20/40–20/400) and 20/30 (range, 20/20–20/100), respectively, and 75% had BSCVA 20/40 or better after REK. The mean corneal thickness in the 28 eyes regrafted for unsatisfactory vision before and after REK was 809 μm (range, 642–979 μm) and 657 μm (range, 549–801 μm), respectively. Secondary graft failure caused by endothelial decompensation was the reason for repeat endothelial graft in the remaining 9 eyes (9/37; 24%). Eight eyes had a history of glaucoma, and 6 of them had glaucoma surgery. An episode of immune rejection reaction was documented in 6 of 9 eyes with endothelial decompensation. Conclusions Our data suggest that the most common reason for REK after DSAEK is unsatisfactory vision. Patient and physician expectations for visual acuity are higher with DSAEK compared with penetrating keratoplasty. Repeat endothelial keratoplasty can provide improved vision in selected patients. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.