Long-Term Graft Survival and Decline in Endothelial Cell Density Following Penetrating Keratoplasty with Organ-Cultured Corneas

Introduction
Endothelial cell density (ECD) changes long after penetrating keratoplasty (PKP) of organ-cultured corneas have been little studied. We aim to calculate the point when ECD decline stabilises following PKP with organ culture stored corneas.

Methods
This is an observational study of first-ever PKPs and first-ever re-grafts, performed over 17 years under a single surgeon. ECDs were acquired at 3 and 6 months, 1 year post-graft and annually thereafter by specular microscopy. Time-dependent ECD data was fitted to a log-biexponential model.

Results
We studied 465 first-ever grafts and 128 re-grafts. Mean recipient age was 59 years (range 0–96 years; SD 22). Median follow-up was 5.7 (range 0.2–17.1) years. Probability of ED at 5 years in first grafts and re-grafts was 4.4% (2.6–7.1%) and 14.8% (8.3–23.2%). In first grafts, ECD loss reached 0.6% per annum at 7.9 (6.2–9.6) years post-operatively. The half-lives of ECD loss during the immediate post-operative period for first grafts, re-grafts, dystrophies, ectasias, and previous ocular surgery are 20.1 (14.9–30.9), 12.8 (6.9–79.4), 19.5 (13.1–37.7), 26.2 (16.2–68), and 11.6 (6.7–41.3) months, respectively. The half-life during this rapid phase of ECD loss has an inverse correlation with graft survival at 10 years (r = − 0.89, p = 0.02).

Conclusions
Rate of endothelial decompensation is higher in first grafts than re-grafts. ECD decline stabilises 7.9 years post-operatively in first grafts but then becomes lower than the physiological loss expected. Further work is needed to verify whether organ-cultured grafts reach physiological levels of ECD loss faster than hypothermically stored grafts.