Failed Descemet-Stripping Automated Endothelial Keratoplasty Grafts: A Clinicopathologic Analysis

PURPOSE: To describe the clinicopathologic findings in failed Descemet-stripping automated endothelial keratoplasty (DSAEK) grafts. DESIGN: Retrospective, interventional case series. METHODS: SETTING: New York Eye and Ear Infir, mary. STUDY POPULATION: Twenty one patients with 22 failed DSAEK grafts treated between March 1, 2006 and February 1, 2008. INTERVENTION: Repeat DSAEK or penetrating keratoplasty were performed in the eyes with failed grafts. All failed grafts were examined histopathologically. MAIN OUTCOME MEASURES: Histopathologic parameters studied in failed DSAEK grafts included endothelial cell count, interface characteristics, retrocorneal membrane formation, inflammation, and immunoreactivity for herpes simplex virus type 1 (HSV-1) antigen. RESULTS: DSAEK failure was strongly associated with postoperative lenticle dislocation. Graft failure was primary in 19 DSAEKs and secondary to rejection, eccentric trephination with epithelial ingrowth, or bacterial infection in the remaining 3. All failed grafts demonstrated endothelial hypocellularity and stromal edema. Additional findings included stromal inflammation (68%), interface fibrosis (50%), retrocorneal membrane (36%), unplanned retention of Descemet membrane (14%), immunoreactivity for HSV-1 (14%), paucicellular stroma. (14%), and uneven trephination with epithelial ingrowth (5%). CONCLUSIONS: Most DSAEK failures are secondary to endothelial cell loss. Other contributing factors include interface fibrosis, retrocorneal membrane formation, re, tained host Descemet membrane, uneven trephination, epithelial ingrowth, graft rejection, and infection. (Am J Ophthalmol 2009;148:752-759. (C) 2009 by Elsevier Inc. All rights reserved.)