Study unveils risk factors for long-term endothelial cell loss after DSAEK

This secondary analysis of the Cornea Preservation Time Study examines factors associated with endothelial cell loss after Descemet stripping automated endothelial keratoplasty (DSAEK).

Study design

The Cornea Preservation Time Study is a double-masked, randomized clinical trial involving 40 U.S. clinical sites and 70 surgeons. Donor corneas were provided by 23 eye banks across the United States. The study included 1,090 participants (1,330 eyes) with Fuchs dystrophy (94%) or pseudophakic/aphakic corneal edema (PACE; 6%) who were randomly assigned to a donor cornea with a preservation time of 0 to 7 days or 8 to 14 days. At 3 years postoperatively, 913 eyes had functioning grafts with acceptable endothelial images and were included in the study.

Outcomes

Factors associated with lower endothelial cell density (ECD) at 3 years included donors with diabetes, lower screening ECD, recipient diagnosis of PACE and operative complications. No other donor, recipient or operative factors were significantly associated with 3-year ECD.

Limitations

The authors acknowledge that their analysis did not include postoperative events such as graft dislocation or rejection that could also be important for ECL and graft survival after DSAEK. In addition, the ECD data were extracted only from surviving recipients and grafts; failed grafts were excluded, potentially introducing a bias. It is unclear whether the results are applicable to DMEK. Finally, causation cannot be inferred from the associations found in this study.

Clinical significance

The factors identified in this study—donor selection, patient diagnosis, intraoperative complications and surgical trauma—are important considerations when performing DSAEK as they could help minimize endothelial cell loss and improve graft survival.