Repeat keratoplasty in failed Descemet stripping automated endothelial keratoplasty

Purpose: To evaluate the clinical factors associated with repeat Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty (PKP) in cases of failed DSAEK. Methods: Retrospective observational study of cases with failed DSAEK admitted to our center for a repeat keratoplasty over 5 years (January 2013–Decemeber 2017) was undertaken. Demographic and perioperative details of all cases and type of repeat keratoplasty were recorded. Logistic regression analysis was performed to analyze the factors affecting the type of repeat keratoplasty. Results: total of 94 eyes with failed DSAEK were evaluated. Repeat DSAEK was performed in 66% and PKP in 34% of cases. Significantly increased odds for requiring PKP were observed in association with stromal scarring [odds ratio (OR) = 2.9, P = 0.018)], trainee surgeons (OR = 4.05, P = 0.008), intraoperative complications (OR = 4.58, P = 0.003), scleral fixated intraocular lens or anterior chamber intraocular lens in situ (OR = 33.8, P < 0.001), secondary glaucoma (OR = 3.02, P = 0.015), peripheral anterior synechiae (OR = 8.6, P < 0.001), preoperative corneal thickness (OR = 1.01, P < 0001), time to primary surgery (OR = 1.03, P = 0.03), post-DSAEK host thickness (OR = 1.01, P < 0.001), and time interval from graft failure to regraft (OR = 1.18, P < 0.001). All eyes with congenital hereditary endothelial dystrophy, bee-sting-induced corneal decompensation, Axenfeld-Rieger syndrome, and multiple failed grafts underwent secondary PKP. All cases (nine eyes) that required surgical intervention for secondary glaucoma underwent secondary PKP (P < 0.001). Conclusion: Repeat DSAEK is feasible in up to two-third of cases of failed DSAEK. A PKP is required in one-third of cases, and various preoperative, intraoperative and postoperative factors are associated with unsuitability for repeat DSAEK.