This study examined the role of donor, recipient, and operative factors in graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK). The authors also examined the effects of graft dislocation and elevated intraocular pressure (IOP) on graft success and endothelial cell density 3 years after surgery.

Study design

This cohort study within the multi-center, double-masked, randomized Cornea Preservation Time Study included 1,330 eyes. Recipients were randomized to a donor preservation time of 0 to 7 days or 8 to 14 days prior to undergoing DSAEK, and then followed for 3 years.

Outcomes

The authors demonstrated that donor diabetes (OR 2.29), operative complications (OR 2.97), and a prelamellar dissection donor corneal thickness greater than 550 microns (OR 1.13 per 25-micron increase) significantly increased the risk of graft dislocation. At 3 years, eyes with dislocated grafts had a higher risk of failure vs eyes without dislocation (HR 7.9). Elevated IOP beyond 1 month after surgery had no significant effect on graft success, whereas acute elevated IOP within the first week increased the rate of failure (HR 3.42).

Limitations

While an overall large study, the number of graft dislocations was still relatively small (104 eyes). Although not statistically significant, eyes with increased IOP after 1 month had an increased hazard ratio of dislocation when examining the 3-year rate of success (HR 1.81 for no prior history of glaucoma vs 2.59 for a history of glaucoma).

Clinical significance

This large cohort study provides further evidence of the detrimental effects of donor diabetes on DSAEK outcomes. Further investigation is needed to parse the effects of increased donor prelamellar thickness.