1. Graft Rejection in Descemet-Stripping Automated Endothelial Keratoplasty
Daniel D. Hayes, MD1; Carolyn Y. Shih, MD1; David C. Ritterband, MD2; John A. Seedor, MD2; Ira J. Udell, MD1
Department of Ophthalmology, North Shore – Long Island Jewish Health System, Great Neck, NY
Department of Ophthalmology, New York Eye and Ear Infirmary, New York, NY
The authors have no financial interest in the subject matter of this presentation

2. Introduction
Descemet-stripping automated endothelial keratoplasty (DSAEK) is rapidly becoming the treatment of choice for endothelial disorders
Indications for DSAEK include Fuchs’ endothelial dystrophy, pseudophakic and aphakic bullous keratopathy, and failed penetrating keratoplasty (PK)

3. Background DSAEK may have a lower rate of rejection compared to PK
Transplanted tissue is placed in the anterior chamber, away from surface antibodies and antigen presenting cells
Fewer sutures may lead to fewer suture-related rejection episodes
No direct contact between host stromal vessels and transplanted tissues
Reduced immunogenicity of transplanted tissue due to absence of epithelium

4. Purpose
To assess the rate of endothelial graft rejection in DSAEK

5. Methods
Retrospective chart review of all DSAEK’s performed at 2 institutions (North Shore-Long Island Jewish Health System and New York Eye and Ear Infirmary) from January, 2006 to April, 2009
Main outcome measure was endothelial graft rejection in patients with at least 6 months follow-up
Endothelial graft rejection defined as presence of Keratic precipitates (KP) or Khodadoust line with associated edema

6. Results Cohort consists of 385 patients
Indications for surgery included Fuchs’ endothelial dystrophy, aphakic and pseudophakic bullous keratopathy and failed PK
There have been 6 patients with endothelial graft rejection (1.56%)
5 were treated successfully
1 failed and required a 2nd DSAEK
This patient had a detachment of her DSAEK lenticle post-operatively, which subsequently spontaneously reattached
4 were using once daily topical steroids
2 were non-compliant with steroids

7. Patient Characteristics
Diagnosis
Fuchs’
Fuchs’ and PBK
PBK
Time to rejection
21 months
1 month
5 months
20 months
On drops? No
Yes
Type of drop
N/A
Lotemax Qday
PredForte Qday
Treatment
PredForte Q2hours and oral medrol
PredForte Q1hour and oral steroids
Lotemax Q2hours
PredForte Q2hours
Time to resolution
1 week
Outcome
Cornea cleared
Regraft (DSAEK)
*2 additional patients had rejection episodes – medical records unavailable
PBK=preudophakic bullous keratopathy, DSAEK=descemet-stripping automated endothelial keratoplasty

8. Figure 1. Color photo of patient 2 showing acute rejection with edema and descemet-folds

9. Figure 2. Color photo of patient 3 showing inflammation, granular interface haze and subtle edema associated with acute rejection

10. Figure 3. Color photo of patient 4 showing acute rejection with Khodadoust line

11. Conclusions
This is the second largest reported series evaluating graft rejection in DSAEK
DSAEK has a low rate of endothelial graft rejection (1.56%) in this series
Previously published rates of rejection are 6% of 118 eyes (7), 7.5% of 199 eyes (1), 9% of 598 eyes (3), 12% of 26 eyes (4) and 14% of 21 eyes (2)
Future study is needed to assess the long-term rate of graft rejection in DSAEK, the role of post-operative steroid drops, and potential risk factors for rejection, as well as to compare with the rate of rejection in PK

12. References
1. Allan BD, Terry MA, Price FW Jr, et al. Corneal transplant rejection rate and severity after endothelial keratoplasty. Cornea 2007; 26:
2. Covert DJ, Koenig SB. New triple procedure: Descemet’s stripping and automated endothelial keratoplasty combined with phacoemulsification and intraocular lens implantation. Ophthalmology 2007; 114:
3. Jordan CS, Price MO, Trespalacios R, et al. Graft rejection episodes after Descemet stripping with endothelial keratoplasty: part one: clinical signs and symptoms. Br J Ophthalmol 2009; 93:
4. Koenig SB, Covert DJ. Early results of small-incision Descemet’s striping and automated endothelial keratoplasty. Ophthalmology 2007; 114:221-6.
5. Prakash G, Jhanji V, Titiyal JS. Will Descemet’s stripping with automated endothelial keratoplasty (DSAEK) lower the rates of allograft rejection in corneal transplants for endothelial failure? Medical hypotheses 2007; 69(5):
6. Shih CY, Ritterband DC, Rubina S, et al. Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty. American Journal of Ophthalmology 2009;148:
7. Suh LH, Yoo SH, Deobhakta A, et al. Complications of Descemet's stripping with automated endothelial keratoplasty. Ophthalmology. 2008;115:1517–1524.