Objective Comparison of conventional Penetrating Keratoplasty (PKP), posterior mushroom PKP and Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) regarding overall graft survival of primary corneal transplants for Fuchs' endothelial dystrophy (FED), best spectacle-corrected visual acuity (BSCVA) and astigmatism. Methods Single centre study using prospectively collected data from the national database for follow-up of corneal transplants. Main outcome parameters: 10 years graft survival, astigmatism at 24 months, pre- and post-operative BSCVA. Results In total, 721 cases were included: PKP, n =171; posterior mushroom PKP, n = 91; and DSAEK, n = 459. There was no significant difference in graft survival between PKP, posterior mushroom PKP and the DSAEK technique (log-rank test, P = 0.12). The overall postoperative BSCVA improvement in all treatment groups was significant (paired t-test, P<0.001). Pre-operative BSCVA was better for the DSAEK group (0.68 +/- 0.41 logMAR) as compared to the PKP (0.89 +/- 0.53) and posterior mushroom PKP group (0.90 +/- 0.58); ANOVA, P<0.001. After 24 months, BSCVA was significantly better for the DSAEK group (0.25 +/- 0.26 log-MAR) compared to the PKP (0.35 +/- 0.29) and posterior mushroom PKP group (0.41 +/- 0.42); ANOVA, P<0.001. A significant difference in astigmatism was found (median test, P<0.001) between the DSAEK (1.7 +/- 1.1 D), PKP (4.6 +/- 2.7 D) and posterior mushroom PKP group (4.5 +/- 3.3 D). The significantly lower DSAEK-induced astigmatism was confirmed by vector analysis. Conclusion There was no difference in graft survival and BSCVA improvement between conventional PKP, inverted mushroom PKP and DSAEK in this study. The significantly lower changes in astigmatism, wound stability and faster visual rehabilitation with DSAEK surgery are favourable aspects of this technique. The benefits of posterior lamellar keratoplasty warrant earlier intervention, which may contribute to preserve better vision for a prolonged period of remaining lifetime.
