Daniel D. Hayes, MD1; Carolyn Y. Shih, MD1; David C

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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

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)

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

Purpose To assess the rate of endothelial graft rejection in DSAEK

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

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

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

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

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

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

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

References 1. Allan BD, Terry MA, Price FW Jr, et al. Corneal transplant rejection rate and severity after endothelial keratoplasty. Cornea 2007; 26:1039-42. 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: 1272-7. 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; 93:387-390. 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):1117-9. 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;148:837-43. 7. Suh LH, Yoo SH, Deobhakta A, et al. Complications of Descemet's stripping with automated endothelial keratoplasty. Ophthalmology. 2008;115:1517–1524.