Histopathological findings of failed grafts following Descemet’s stripping automated endothelial keratoplasty (DSAEK)

Purpose: To study the histopathological findings of the early cases of failed DSAEK grafts and to analyze the causes of graft failure. Methods: Retrospective study of 13 failed DSAEK grafts (four grafts submitted alone with no host cornea) of 12 patients. The histopathologic features are correlated with the clinical and operative findings. Results: Significant attenuation of the endothelial cells found in 10/13 cases (77%), retained recipient Descemet’s membrane in 7/ 13 (54%), variability of graft thickness in 5/13 (38%) and two of these had stromal irregularity. Retrocorneal fibrous membrane along the donor’s Descemet’s membrane was found in 4/13 (31%) resulting in endothelial detachment in one case. Eight of the nine host cornea–graft specimens were found to have: total graft-cornea detachment (in one), subtotal in four and partial (650% of graft length) in three. The detached flaps showed infection at the interface of the graft–host cornea in two, epithelial ingrowth and fibrous proliferation along the anterior stromal surface of the graft (one case each). An additional histopathological finding was secondary amyloid deposition within the host stroma (in one).Conclusion: Irregular or thick graft, graft–host interface fibrous/epithelial ingrowth, and infection all predispose to DSAEK failures related to graft detachment. Endothelial cells attenuation and retrocorneal fibrous membrane are major causes for primary graft failure.