Descemet's Membrane Endothelial Keratoplasty: Risk of Immunologic Rejection Episodes after Discontinuing Topical Corticosteroids

Ophthalmology. 2016 Jun;123(6):1232-6. doi: 10.1016/j.ophtha.2016.02.001. Epub 2016 Mar 13.


Purpose: To assess the risk of immunologic rejection episodes if topical corticosteroids are discontinued 1 year after Descemet's membrane endothelial keratoplasty (DMEK) compared with continued once-per-day use.

Design: Prospective, longitudinal, parallel-group study.

Participants: A total of 400 eyes of 259 DMEK recipients, aged 23 to 90 years.

Methods: Patients were enrolled 1 year after DMEK and allowed to choose whether to stop or continue once-daily topical corticosteroids to maximize compliance. Fellow eyes were eligible for enrollment because the donor grafts were independent. Participants were examined at 1, 3, 6, and 12 months during the second year after DMEK. Results were assessed using Kaplan-Meier survival analysis.

Main outcome measures: Incidence of immunologic rejection episodes.

Results: Steroids were discontinued in 277 eyes (no steroid group) and continued once per day in 123 eyes (steroid group). The subject demographics were well balanced across groups; 99% of the subjects were white, and 95% of the grafts were performed to treat Fuchs' dystrophy. The cumulative incidence of rejection episodes was significantly greater in the no steroid group (6% vs. 0% in the steroid group; P = 0.013). Thirteen of 14 rejection episodes (all in the no steroid group) resolved with resumption of topical corticosteroids. Overall, 1 of 277 grafts (0.4%) failed in the no steroid group, and none failed in the steroid group during the second year after DMEK (P = 0.49). The endothelial cell loss between 1 and 2 years was comparable in the no steroid and steroid groups (6.4%±12% vs. 5.6%±14%, respectively; P = 0.67).

Conclusions: Continued once-per-day use of a topical corticosteroid, even a weak one, was protective against rejection episodes during the second year after DMEK, whereas 6% experienced a rejection episode when steroids were discontinued. Among the 364 eyes that completed 12 months' follow-up, only 1 graft (0.27%) failed.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Topical
  • Adult
  • Aged
  • Aged, 80 and over
  • Cell Count
  • Corneal Endothelial Cell Loss / diagnosis
  • Descemet Stripping Endothelial Keratoplasty*
  • Endothelium, Corneal / pathology
  • Female
  • Fluorometholone / administration & dosage
  • Fuchs' Endothelial Dystrophy / surgery
  • Glucocorticoids / administration & dosage*
  • Graft Rejection / epidemiology*
  • Graft Rejection / immunology
  • Graft Rejection / prevention & control
  • Graft Survival / drug effects
  • Humans
  • Longitudinal Studies
  • Loteprednol Etabonate / administration & dosage
  • Male
  • Middle Aged
  • Ophthalmic Solutions
  • Prednisolone / administration & dosage
  • Prednisolone / analogs & derivatives
  • Prospective Studies
  • Risk Factors
  • Withholding Treatment*
  • Young Adult


  • Glucocorticoids
  • Ophthalmic Solutions
  • prednisolone acetate
  • Prednisolone
  • Fluorometholone
  • Loteprednol Etabonate