Long-term Outcomes of Endothelial Keratoplasty Win Over Penetrating Keratoplasty

Christopher J. Rapuano, MD


January 17, 2017

Changing Practice Patterns and Long-term Outcomes of Endothelial Versus Penetrating Keratoplasty: A Prospective Dutch Registry Study

Dickman MM, Peeters JM, van den Biggelaar FJ, et al
Am J Ophthalmol. 2016;170:133-142

Study Summary

The authors looked at the changing practice patterns in corneal transplantation and compared the long-term outcomes of Descemet stripping endothelial keratoplasty (EK) with penetrating keratoplasty (PK).

They reviewed the graft survival, visual acuity, refractive error, and endothelial cell density (ECD) for the treatment of Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK) based on prospectively collected data from The Netherlands Organ Transplantation Registry. The registry includes all consecutive primary Descemet stripping EKs and PKs performed in The Netherlands for the treatment of FED or PBK between January 1, 1998, and December 31, 2013.

This study included 2725 EKs and 2390 PKs. The overall lost-to-follow-up rate was 19% for EK and 31% for PK; but, since EK became widely performed in The Netherlands in 2007, the lost-to-follow-up rate has been 19% for EK and 16% for PK. The 5-year follow-up data were the longest evaluated in this study.

The 2-year graft survival was statistically significantly higher for PK than EK for both FED (97.4% vs 95.2%) and PBK (94.5% vs 88.7%). Approximately one third of the EK grafts failed due to primary graft failure, whereas only 2%-3% of PK grafts failed due to primary graft failure. Graft survival from year 2 to year 5 was statistically significantly higher in the EK eyes than the PK eyes (98.2% vs 95.2% for FED and 97.2% vs 85.9% for PBK). At 5 years, no difference in graft survival was found between the two groups (FED: 94% for EK and 93.3% for PK; PBK: 87.3% for EK and 84.1% for PK). Not surprisingly, the researchers found greatly improved 2-year graft survival rates for the EKs performed more recently, indicating a significant learning curve for this procedure. Survival rates remained stable for PK over the study period. In fact, for EKs performed between 2012 and 2014, the 2-year graft survivals were almost identical to those for PKs.

Best corrected visual acuity, correcting for preoperative differences, was statistically better for EK than PK performed for FED up to 3 years, but visual acuity was similar in the two groups after that. EK yielded better vision than PK for PBK throughout the 5-year follow-up. As expected, PK had statistically significantly greater spherical equivalent refractions and refractive astigmatism than EK throughout the follow-up period. ECD was lower for the first 2-3 years postoperatively for EK than PK but evened out after that and was similar for FED and PBK.


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