Factors Influencing Graft Endothelial Cell Density after Descemet Stripping Automated Endothelial Keratoplasty

Purpose: To determine the factors that influence the endothelial cell density (ECD) of donor grafts after Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: This retrospective, interventional case series comprised 77 eyes of 64 patients who underwent DSAEK. Confocal microscopy was performed at the final follow‑up examination to evaluate the endothelial cell count, cell morphology, and graft thickness. Univariate and multiple linear regression analyses were used to investigate recipient‑, donor‑, surgical‑, and postoperative related variables capable of influencing graft endothelial cell counts after DSAEK. Results: The mean patient age was 62.3 ± 15.6 years; patients were followed‑up for 26.2 ± 20.9 months postoperatively. Forty‑six eyes (59.7%) underwent stand‑alone DSAEK; 31 eyes (40.3%) underwent DSAEK combined with cataract surgery. The donor trephination size was 8.0 ± 0.21 mm. The mean donor age was 30.4 ± 11.2 years, and the mean preoperative endothelial cell density was 3127.4 ± 315.1 cells/mm2, which decreased to 1788.6 ± 716.5 cells/mm2 postoperatively (P < 0.001). The mean postoperative central graft thickness was 102.4 ± 31.6 μm. Univariate analysis revealed that postoperative ECD was significantly associated with death to preservation time (P = 0.046), graft thickness (P = 0.016), follow‑up duration (P = 0.005), and graft non‑attachment (P = 0.049). Multiple regression analyses identified graft thickness (β = 10.62, P = 0.003) and follow‑up duration (β = ‑22.09, P = 0.001) as the significant characteristics influencing postoperative ECD. Conclusion: The primary predictors of ECD after DSAEK were graft thickness and duration of follow‑up. Surgeons’ requests for ultrathin DSAEK donor grafts to improve visual outcomes might not have the desired postoperative outcome with respect to ECD.