Long-term outcomes of repeated Corneal Transplantations: a prospective Dutch registry study

Purpose: To compare long-term outcomes of repeated corneal transplantations (CT), based on primary indication (Fuchs endothelial dystrophy [FED] vs pseudophakic bullous keratoplasty [PBK]), surgical technique (penetrating keratoplasty [PK] vs endothelial keratoplasty [EK]), and indication for repeated grafting. Methods: In this nonrandomized treatment comparison with national registry data (Netherlands Organ Transplantation Registry, NOTR), data on all consecutive repeated CT following primary PK or EK for FED and PBK between 1994 and 2015 were analyzed, with a maximal follow-up of 5 years. Regraft survival was analyzed using Kaplan-Meier survival curves and univariable and multivariable Cox regression analysis. Secondary outcomes best-corrected visual acuity, spherical equivalent, and refractive astigmatism were compared using linear mixed-model analysis. Results: A total of 332 repeated CT were analyzed. The number of regrafts increased significantly between 2007 and 2015 (P =.001). Overall 5-year regraft survival was 60% and was higher for FED vs PBK (77% vs 45%, HR = 0.40, P =.001), and re-EK vs re-PK (81% vs 55%, HR = 0.51, P =.041). However, multivariable analysis showed no significant difference in survival based on primary indication, surgical technique, and indication for regrafting. Corrected for baseline, secondary outcomes also did not differ between groups. Conclusions: We found a significant increase in repeated CT, coinciding with the introduction of EK in the Netherlands. While univariable analysis suggested better overall regraft survival for FED and (re-)EK, multivariable analysis showed no such difference. This may be owing to allocation of favorable cases to undergo (re-)EK. Similarly, secondary outcomes were determined by the primary CT technique.