Changing Practice Patterns and Long-term Outcomes of Endothelial Versus Penetrating Keratoplasty: A Prospective Dutch Registry Study

Abstract

To compare graft survival, best-corrected visual acuity (BCVA), endothelial cell density (ECD), and refraction following penetrating keratoplasty (PK) vs endothelial keratoplasty (EK) for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK). Nonrandomized treatment comparison with national registry data. All consecutive patients undergoing first keratoplasty for FED and PBK between 1998 and 2014were analyzed, with a maximum follow-up of 5years(mean ± SD follow-up 39 ± 20months, range 0-60months). Graft survival was analyzed using Kaplan-Meier survival curves and Cox regression analysis. BCVA, ECD, and refractive error were compared using linear mixed models. Main outcome measures were graft survival, BCVA, refraction, and ECD. A total of 5115 keratoplasties (PK= 2390; EK= 2725) were identified. Two-year graft survival following EK was lower compared with PK (94.5% vs 96.3%, HR= 1.56, P= .001). Five-year survival wascomparable for EK and PK (93.4% vs 89.7%, HR= 0.89, P= .261). EK graft survival improved significantly over time while remaining stable for PK. One-year BCVA was better following EK vs PK (0.34 vs 0.47 logMAR, P < .001). Astigmatism was lower 1 year after EK vs PK (-1.69 vs-3.52 D, P < .001). One-year ECD was lower after EK vs PK (1472 vs 1859 cells/mm2, P < .001). At 3 years, ECD did not differ between EK and PK. Long-term graft survival after EK and PK is high and comparable despite lower short-term survival for EK. EK graft survival improved over time, suggesting a learning curve. EK results in better BCVA, lower astigmatism, and similar long-term ECD compared with PK for FED and PBK.