Donor and surgical risk factors for primary graft failure following Descemet's stripping automated endothelial keratoplasty in Asian eyes

Background: Descemet's stripping automated endothelial keratoplasty (DSAEK) has been shown to have superior refractive and visual results compared with penetrating keratoplasty, but higher rates of primary graft failure (PGF). This paper presents donor and surgical risk factors for PGF in DSAEK cases in Asian eyes. Design: Retrospective case-control study. Participants: All consecutive patients who underwent DSAEK at a tertiary referral teaching hospital from March 2006-December 2008. Methods: Donor details analyzed were: age of donor, cause of donor death, death to harvesting time, donor storage time, distribution distance of tissue, preoperative endothelial cell count. Surgical factors analyzed were: donor diameter, donor thickness, and method of donor insertion. These risk factors in cases of PGF were compared with patients with successful DSAEK as the control group. Main outcome measure: PGF. Results: A total of 124 DSAEK procedures were performed. Six DSAEK procedures (five eyes of five patients; one eye with two failures) resulted in PGF (4.8%). Significant risk factors were found for PGF to include graft insertion using a folding technique (odds ratio [OR], 34.03; 95% confidence interval [CI], 3.75-314.32; P = 0.0017) and a small donor diameter (OR, 39.94; 95% CI, 2.18-732.17; P = 0.013). Conclusion: The results of this study suggest that in Asian eyes with shallow anterior chambers, surgical trauma relating to the technique of donor insertion, and the use of a small donor are major risk factors for PGF following DSAEK.