Half of grafts fail by three years after keratoplasty in post-glaucoma-surgery eyes

Design

Systematic review and meta-analysis of 22 retrospective studies; random-effects proportions

Population

943 endothelial keratoplasty grafts (656 DSAEK, 287 DMEK) in eyes with prior glaucoma surgery

Primary outcome

Graft survival at 36 months

Effect

57% overall survival (48–66%); 50% in drainage-device eyes; endothelial cell loss 63% at 12 months

Endothelial keratoplasty in an eye that has had glaucoma surgery is known to be higher risk, but the scale was unclear. This meta-analysis pooled 22 studies and 943 grafts to quantify survival and complications, and to compare DSAEK with DMEK.

Three-year graft survival was 57% overall and just 50% in eyes with a glaucoma drainage device. Endothelial cell loss in those eyes was steep — 53% at six months and 63% at twelve — and graft dislocation was commoner (19%). DSAEK was numerically favoured over DMEK from 24 months, especially in drainage-device eyes, but head-to-head there was no significant difference through 24 months; rejection was 8–9% and primary failure low at 4–5%.

The usable message is for consent and planning. Tell a patient with prior glaucoma surgery, particularly a drainage device, that only about half of grafts last three years, and factor that into timing, technique choice and the threshold for listing. The data are retrospective, so treat the DSAEK signal as hypothesis-generating rather than a rule.

• Three-year graft survival was 57% overall and 50% in eyes with a glaucoma drainage device.
• Endothelial cell loss reached 53% at 6 months and 63% at 12 months in drainage-device eyes.
• Graft dislocation was higher in drainage-device eyes (19% vs 15% overall); rejection 8–9%, primary failure 4–5%.
• Counsel the elevated failure risk explicitly before keratoplasty in a post-glaucoma-surgery eye.

Why it matters

It puts a hard number on a risk often described only vaguely, changing how the operation is consented and planned.

Don't overread it

Twenty-two retrospective studies — the DSAEK-versus-DMEK signal is indirect and hypothesis-generating, not a demonstrated superiority.

The statistics, in plain English

A 57% three-year survival with a confidence interval of 48–66% means the true figure is poor however you read it. The DSAEK advantage was 'indirect' — inferred across studies rather than from head-to-head trials — so it is weaker than a direct comparison would be.

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