Center and surgeon effect on outcomes of endothelial keratoplasty versus penetrating keratoplasty in the United Kingdom

Am J Ophthalmol. 2014 Nov;158(5):957-66. doi: 10.1016/j.ajo.2014.07.037. Epub 2014 Aug 1.


Purpose: To compare national outcomes of endothelial keratoplasty (EK) and penetrating keratoplasty (PK) during comparable 6-year periods.

Design: Prospective cohort study of national registry data.

Setting: United Kingdom National Transplant Registry, 2000 through 2011, inclusive.

Patient population: All United Kingdom patients undergoing first EK (n = 2074) for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy from January 2006 through December 2011. Comparison cohort of patients undergoing first PK (n = 2622, same indications, January 2000 through December 2005).

Observation procedure: Year of surgery, surgeon and center experience, corneal diagnosis, donor factors, patient factors, and surgical risk factors were analyzed against graft survival and visual outcomes.

Results: For both Fuchs endothelial dystrophy and pseudophakic bullous keratopathy, EK achieved better average best-corrected acuity and lower refractive error. For both groups, graft failure was significantly higher for EK than PK. EK failure in Fuchs endothelial dystrophy was associated with center experience (hazard ratio [HR], 2.3; P < .0001), donor endothelial density (HR, 1.8; P = .01), glaucoma at time of surgery (HR, 2.1; P = .003), and donor age older than 75 years (HR, 1.3; P = .05). EK failure in pseudophakic bullous keratopathy was associated with center experience of fewer than 15 cases (HR, 2.0; P < .0001) and glaucoma at time of surgery (HR, 1.7; P = .002).

Conclusions: Prospective national registry data for EK showed higher graft failure than is seen in PK or in retrospective case series of EK. Higher failure rates may be acceptable given established benefits of the procedure, including lower refractive error, structural globe integrity, and faster visual recovery. Center experience influenced EK survival more than surgeon experience, and overall surgical outcomes may be improved by standardized techniques and support within experienced units.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Child
  • Child, Preschool
  • Clinical Competence*
  • Descemet Stripping Endothelial Keratoplasty / methods*
  • Endothelium, Corneal / transplantation*
  • Female
  • Follow-Up Studies
  • Fuchs' Endothelial Dystrophy / surgery*
  • Graft Rejection / epidemiology*
  • Humans
  • Incidence
  • Infant
  • Infant, Newborn
  • Keratoplasty, Penetrating / methods*
  • Male
  • Middle Aged
  • Prospective Studies
  • Surgicenters / statistics & numerical data*
  • Treatment Outcome
  • United Kingdom / epidemiology
  • Visual Acuity