Corneal transplantation for Fuchs´ endothelial dystrophy: A comparison of three surgical techniques concerning 10 year graft survival and visual function

Outcomes of Penetrating Keratoplasty Versus Lamellar Endothelial Keratoplasty in Iridocorneal Endothelial Syndrome: A Systematic Review and Meta-Analysis

PURPOSE

To compare surgical outcomes following penetrating keratoplasty (PK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet membrane endothelial keratoplasty (DMEK) in patients with iridocorneal endothelial (ICE) syndrome.

DESIGN

Systematic review and meta-analysis on individual patient data (IPD).

METHODS

Pre-registration was performed in the PROSPERO database (registration number: CRD42024539444). Eligible studies from Embase, MEDLINE (via PubMed), and the Cochrane Central Register of Controlled Trials (CENTRAL) were retrieved up to April 24, 2024. Studies were included those reporting clinical outcomes after PK, DSEK, or DMEK- graft survival, best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) - in people with ICE syndrome. Cochrane Handbook was followed for data extraction/ synthesis, and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) and the Joanna Briggs Institute Critical Appraisal Checklists were used to assess risk of bias. Meta-analyses were conducted using a random-effects model. Heterogeneity between studies was assessed using Q-test and I2 statistics.

RESULTS

Nineteen of the 1963 screened studies were included in the meta-analysis. Multivariate pooled Kaplan-Meier curves with 95% confidence intervals, based on IPD from studies with at least 10 cases indicated that graft survival was better after PK compared to DSEK in patients with ICE syndrome. No significant difference (P = .92) was found in BSCVA improvement between PK [-0.77 (95% CI, -1.45 to -0.09)], DSEK [-0.87 (95% CI, -1.35 to -0.39)] and DMEK [-0.85 (95% CI, -1.07 to -0.62)]. No significant differences in ECD were observed between DSEK and DMEK 6 (P = .88) and 12 months (P = .33) postoperatively. IPD analysis revealed no significant difference in graft survival between patients with and without anytime glaucoma (-0.04 ± 0.50 SEM; P = .940) or cataract surgery (-0.45 ± 0.40 SEM; P = .265).

CONCLUSIONS

PK demonstrated better graft survival compared to DSEK in patients with ICE, however, further research and additional evidence are needed to draw more definitive conclusions. Improvements in BSCVA were comparable across PK, DSEK and DMEK. Glaucoma surgery, whether performed before or after keratoplasty, appear to have no significant impact on graft survival.

Exploring single-cell RNA sequencing as a decision-making tool in the clinical management of Fuchs' endothelial corneal dystrophy

Single-cell RNA sequencing (scRNA-seq) has enabled the identification of novel gene signatures and cell heterogeneity in numerous tissues and diseases. Here we review the use of this technology for Fuchs' Endothelial Corneal Dystrophy (FECD). FECD is the most common indication for corneal endothelial transplantation worldwide. FECD is challenging to manage because it is genetically heterogenous, can be autosomal dominant or sporadic, and progress at different rates. Single-cell RNA sequencing has enabled the discovery of several FECD subtypes, each with associated gene signatures, and cell heterogeneity. Current FECD treatments are mainly surgical, with various Rho kinase (ROCK) inhibitors used to promote endothelial cell metabolism and proliferation following surgery. A range of emerging therapies for FECD including cell therapies, gene therapies, tissue engineered scaffolds, and pharmaceuticals are in preclinical and clinical trials. Unlike conventional disease management methods based on clinical presentations and family history, targeting FECD using scRNA-seq based precision-medicine has the potential to pinpoint the disease subtypes, mechanisms, stages, severities, and help clinicians in making the best decision for surgeries and the applications of therapeutics. In this review, we first discuss the feasibility and potential of using scRNA-seq in clinical diagnostics for FECD, highlight advances from the latest clinical treatments and emerging therapies for FECD, integrate scRNA-seq results and clinical notes from our FECD patients and discuss the potential of applying alternative therapies to manage these cases clinically.

Donor lamella thickness after ultrathin Descemet stripping automated endothelial keratoplasty and its relation to postoperative visual acuity and pre-operative lamella measures

BACKGROUND

To accurately measure ultrathin Descemet stripping automated endothelial keratoplasty (DSAEK) donor lamella thickness during the first postoperative year and to correlate this with pre-operative and other postoperative measurements.

METHODS

Donor lamella thickness in 41 eyes undergoing DSAEK for Fuchs endothelial dystrophy (FED) was measured using the Tomey Casia OCT directly after graft preparation and at 1 week and 1, 3, 6 and 12 months postoperatively. Visual acuity and endothelial cell density were measured as the secondary parameters.

RESULTS

Individual graft thickness profiles were shown to be fairly regular within the optically relevant area. There was a strong and highly significant correlation between the pre- and postoperative lamellar thicknesses at all time points (p < 0.0001). Compared with the measurements directly after preparation at the cornea bank, the lamella thickness decreased by 12% after 12 months. Between 1 and 12 months postoperatively, the lamella thickness (mean ± SD) changed from 112 ± 27 μm to 101 ± 21 μm. Best spectacle-corrected visual acuity (BSCVA) changed from 0.46 ± 0.30 logMAR pre-operatively through 0.36 ± 0.33 at 1 month to 0.13 ± 0.16 at 1 year postoperatively. The endothelial cell counts were comparable to those reported in previous studies.

CONCLUSIONS

Thickness profiles of individual grafts were fairly regular within the optically relevant area. A strong relationship between pre- and postoperative graft thicknesses was detected, and ultrathin DSAEK grafts prepared using methods similar to that applied in this study are expected to show a deswelling of around 12% during the first postoperative year. No correlation was detected between graft thickness and BSCVA.

Graft Survival, Graft Rejection, and Glaucoma in a Consecutive Series of Descemet Stripping Endothelial Keratoplasty

PURPOSE

The goal of this study was to compare outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma and abnormal anatomy to eyes with Fuchs endothelial corneal dystrophy (FECD).

METHODS

In a retrospective interventional series of all cases of DSEK between April 1, 2006, and November 30, 2015, recipient diagnosis, preoperative glaucoma status, concurrent surgical procedures, and graft outcomes were recorded. Graft survival, risk of rejection, and subsequent glaucoma surgery were estimated by using Kaplan-Meier analysis with risk factors determined by proportional hazard models.

RESULTS

Of 703 DSEKs in 666 eyes (509 subjects), the main recipient diagnoses were FECD (n = 496), pseudophakic corneal edema (n = 112), and failed graft (n = 83). Glaucoma was present in 150 cases before DSEK. Overall graft survival was 85%, 75%, and 71% at 5, 10, and 12 years, respectively, and for FECD without glaucoma was 95%, 89%, and 87% at 5, 10, and 12 years, respectively. Independent risk factors for graft failure included recipient diagnoses of pseudophakic corneal edema (HR = 8.3, P < 0.001), failed graft (HR = 6.4, P < 0.001), and preoperative medical glaucoma (HR = 7.1, P < 0.001) or surgical glaucoma (HR = 12.3, P < 0.001). Preoperative glaucoma treated by previous surgery resulted in graft survival of 28% at 10 years. Preoperative glaucoma was associated with an increased risk of graft rejection (HR = 6.8, P < 0.001) and subsequent glaucoma surgery (HR > 17.4, P < 0.001).

CONCLUSIONS

Preoperative glaucoma increases the risk of graft failure, graft rejection, and needing subsequent glaucoma surgery in the first decade after DSEK. With previous glaucoma surgery, DSEK graft survival was more favorable compared with published reports of Descemet membrane endothelial keratoplasty.

Long-term Outcomes After Lamellar Endothelial Keratoplasty Compared With Penetrating Keratoplasty for Corneal Endothelial Dysfunction: A Systematic Review

PURPOSE

The purpose of this study is to evaluate long-term outcomes of endothelial keratoplasty (EK) compared with penetrating keratoplasty (PK) for corneal endothelial dysfunction [Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK)].

METHODS

In this systematic review, we searched PubMed, the Cochrane Library, and Embase up to May 2022 and considered all types of studies addressing our objective. Graft survival at 5, 10, and 15 years was the main outcome.

RESULTS

Fifty cohort studies were included. At 5 years, in FECD and BK, graft survival seemed higher after EK than PK. Two comparative studies showed either a higher 5-year graft survival after EK than PK or no significant differences. Including noncomparative studies, in FECD, the 5-year graft survival ranged from 0.69 to 0.98 for PK, from 0.93 to 1.00 for DSEK, and from 0.93 to 0.99 for Descemet membrane endothelial keratoplasty (DMEK). In BK, the 5-year graft survival ranged from 0.39 to 0.91 for PK, from 0.65 to 0.89 for DSEK, and from 0.84 to 0.95 for DMEK. The 10-year graft survival ranged from 0.20 to 0.90 for PK and from 0.62 to 0.92 for EK. The mean 5-year best spectacle-corrected visual acuity ranged from 0.73 to 0.43 LogMAR for PK, from 0.61 to 0.09 for DSEK, and from 0.31 to 0.05 for DMEK. The 5-year rejection rate ranged from 11.0% to 28.7% for PK, from 5.0% to 7.9% for DSEK, and from 1.7% to 2.6% for DMEK.

CONCLUSIONS

These results suggest a higher 5-year graft survival and better secondary outcomes after EK. Nevertheless, the level of evidence was low.

PROSPERO REGISTRATION

CRD42021260614.

An Overview of Corneal Transplantation in the Past Decade

The cornea is a transparent avascular structure located in the front of the eye that refracts light entering the eyes and also serves as a barrier between the outside world and the internal contents of the eye. Like every other body part, the cornea may suffer insult from trauma, infection, and inflammation. In the case of trauma, a prior infection that left a scar, or conditions such as keratoconus that warrant the removal of all or part of the cornea (keratoplasty), it is important to use healthy donor corneal tissues and cells that can replace the damaged cornea. The types of cornea transplant techniques employed currently include: penetrating keratoplasty, endothelial keratoplasty (EK), and artificial cornea transplant. Postoperative failure acutely or after years can result after a cornea transplant and may require a repeat transplant. This minireview briefly examines the various types of corneal transplant methodologies, indications, contraindications, presurgical protocols, sources of cornea transplant material, wound healing after surgery complications, co-morbidities, and the effect of COVID-19 in corneal transplant surgery.

Evaluating Keratoplasty for Fuchs' Endothelial Corneal Dystrophy: A Literature Review

Fuchs' endothelial corneal dystrophy (FECD) is progressive corneal endothelium dysfunction, characterised by corneal oedema, and potential blindness if left untreated. Keratoplasty is the only definitive treatment to restore vision in FECD, with different surgical techniques being described. The corneal transplant has been described as the most commonly performed and most successful allogenic transplant globally; therefore, it is crucial to dissect it further since a large proportion of the population worldwide is likely to be impacted. We feel that an updated literature review is both very relevant and necessary at present and aim to amalgamate more recent data on the topic (including meta-analyses, systematic reviews, and randomised control trials (RCTs), among others). We acknowledge that the paucity of reliable data limits progress for FECD and that there are existing ethical complexities in performing prospective trials on patients.  Traditionally, the surgery for FECD was limited to penetrating keratoplasty (PK), yet recent developments have introduced more advanced procedures and adapted the existing ones, to provide treatment specific to the disease-affected corneal layers. The questions we will address encompass: how does the severity of FECD govern the treatment options available, what are the differences between PK and types of endothelial keratoplasty (EK), what are the expected clinical outcomes of each of these operations, what are the potential concerns with the idealistic descemetorhexis surgery, and what do we envisage for times to come? Besides this, novel minimally-invasive pharmacological techniques are now being trialled, such as Rho kinase (ROCK) inhibition and cultured endothelial cells (CECs), which may drastically improve the dependence on corneal donors. We examine and critically appraise the literature to explore the understanding of FECD, and the treatment options that exist: historically, currently, and those anticipated for the future.

Case series of staged lamellar corneal grafting with thin manual Descemet's stripping endothelial keratoplasty, followed by manual deep anterior lamellar keratoplasty, as an alternative to penetrating keratoplasty

The purpose of this report is to present the outcomes of Descemet's stripping endothelial keratoplasty (DSEK), followed by deep anterior lamellar keratoplasty (DALK), as an alternative to penetrating keratoplasty (PKP) for different indications. Patients in this retrospective case series underwent manual DSEK, followed by manual DALK, for tectonic and/or visual reasons. It includes three cases that underwent DSEK followed by DALK as an alternative to PKP for the following conditions: failed PKP and stromal scarring, aphakic bullous keratopathy and herpetic stromal scarring, and herpetic corneal perforation. All cases had successful anatomical repair with visual improvement. Many corneal conditions involving endothelium and stroma have been traditionally managed with PKP. However, in certain settings with high risk of complications, this might not be an appropriate option. Therefore, for these cases, we propose management with DSEK followed by DALK as an alternative approach in a 'closed anterior chamber' fashion, which can reduce the risk of significant, sometimes irreversible, complications.

Current Perspectives on Corneal Transplantation

Disease of the cornea is the third leading cause of blindness worldwide. Corneal graft surgery is one of the most successful forms of solid organ transplantations in humans, with ever-increasing developments in surgical technique. To date, approximately 4504 corneal transplants are performed in the United Kingdom each year. While full thickness transplantation was the most commonly performed keratoplasty over the last few decades, selective lamellar transplantation of the diseased layers of the cornea has been universally adopted. This comprehensive review aims to provide an updated synthesis on different types of corneal transplantations, their treatment outcomes, and the associated complications of each procedure in both adult and paediatric population. In addition, we also present an up-to-date summary of the emerging therapeutic approaches that have the potential to reduce the demand for donor-dependent keratoplasty.

Long-term Outcomes of Descemet Stripping Endothelial Keratoplasty: Ten-Year Graft Survival and Endothelial Cell Loss

PURPOSE

To determine 10-year outcomes for graft and endothelial cell survival after Descemet stripping endothelial keratoplasty (DSEK), including risk factors for graft failure.

DESIGN

Retrospective clinical cohort study.

METHODS

Three hundred fifty-six consecutive DSEK grafts performed by 10 surgeons using a standardized protocol were analyzed. Primary outcomes were cumulative graft survival and percentage endothelial cell loss (ECL) from 6 months to 10 years; secondary outcomes included risk factors for graft failure, postoperative complications, visual outcomes, and central corneal thickness.

RESULTS

Indications include Fuchs endothelial dystrophy (n = 209), bullous keratopathy (n = 88), and previous graft failure (n = 39). One hundred and four eyes (29%) had preoperative glaucoma. Cumulative graft survival rates of all eyes at 1, 3, 5, and 10 years were 97%, 90%, 85%, and 79%, respectively. Ten-year graft survival for Fuchs endothelial dystrophy was 92%. Mean ± SD percentage ECL of all grafts was 46.6% ± 17.3% at year 1, 54.9% ± 18.7% at year 3, 59.6% ± 17.4% at year 5, and 73.1% ± 9.7% at year 10. Cox regression identified preoperative glaucoma (hazard ratio [HR]: 8.41; 95% CI, 1.30-54.5; P = .026), including previous glaucoma surgery (HR: 3.63; 95% CI: 1.03-12.74; P = .04) and regrafts (HR: 5.29; 95% CI: 2.02-13.89; P = .001) as significant risk factors for graft failure.

CONCLUSIONS

At 10 years, DSEK survival rate was 79% for all eyes, including complex grafts, and ECL was 73%. For Fuchs endothelial dystrophy, 10-year graft survival rate was 92%. Despite a mean 10-year endothelial cell count of only 692 cells/mm², graft survival remained high with good vision. DSEK continues to be a viable treatment option, especially in complex eyes with comorbidity.

Descemet Membrane Endothelial Keratoplasty versus Descemet Stripping Automated Keratoplasty - Outcome of One Single Surgeon's More Than 200 Initial Consecutive Cases

Purpose

To compare clinical outcome and complications of Descemet stripping automated keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK).

Methods

This is a retrospective study of the first consecutive cases of DSAEK and DMEK performed by a single surgeon at a tertiary referral centre. Best-corrected visual acuity (BCVA), postoperative complications, rate of rebubbling and regraft were the main outcome measures.

Results

The study included 241 eyes, 116 subjected to DSAEK and 125 to DMEK. Fuchs endothelial dystrophy (FED) was the predominant diagnosis in both groups. Mean BCVA at all follow-ups up to 2 years was in favour of DMEK. Median BCVA (decimal) at 1 year was 0.4 (0.13–0.60; interquartile range) for the DSAEK and 0.8 (0.6–1.0) for the DMEK group, p<0.001. Preoperative BCVA in the DSAEK group was lower than in DMEK. There was no significant difference in visual improvement between groups at 1 year postoperatively. The most common postoperative complication in both groups was a pupillary block with high intraocular pressure, 27% and 34% respectively. This was not affected by the presence of an iridectomy/iridotomy. In the DMEK group, gas provided significantly better adherence than air (p=0.020). Rebubbling for partial/total detachment was performed in 7% (DSAEK) and 11% (DMEK) of cases, p=0.361. Regraft within 2 years was performed in 13% of eyes in the DSAEK and 17% in the DMEK group, p=0.450. No case of graft rejection occurred.

Conclusion

Both DSAEK and DMEK provide overall satisfying outcome and the two techniques do not differ significantly in postoperative pupillary block, detachment rate, early graft failure or graft rejection. However, differences at baseline may have influenced or obscured potential differences. In DMEK procedures, gas seems to facilitate early graft adherence.

Real-World Outcomes of DMEK: A Prospective Dutch registry study

PURPOSE

This study analyzed real-world practice patterns, graft survival, and outcomes of Descemet membrane endothelial keratoplasty (DMEK) in the Netherlands.

DESIGN

Population-based interventional clinical study.

METHODS

In this prospective registry study, all consecutive primary DMEK procedures registered in the Netherlands Organ Transplant Registry were identified. Short-term graft survival and outcomes of primary transplants for Fuchs' endothelial dystrophy (FED) were analyzed using Kaplan-Meier survival curves with log-rank test and Cox regression. Linear mixed model analyses were used for best spectacle-corrected visual acuity (BSCVA), spherical equivalent, hyperopic shift, and endothelial cell density.

RESULTS

752 DMEKs were identified between 2011 and 2018. In 90% of cases, the indication for DMEK was FED. Graft survival measured 87% at 3 months, 85% at 6 months, 85% at 1 year, and 78% at 2 years. DMEK procedures after 2015 showed better survival compared to previous years (Hazard ratio = 0.4; P < .001). Baseline BSCVA in primary transplants with FED measured on average 0.45 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI], 0.41-0.49), and significantly improved (overall P < .001) to 0.17 logMAR (95% CI, 0.14-0.21) at 3 months, 0.15 logMAR (95% CI, 0.11-0.18) at 6 months, 0.12 logMAR (95% CI, 0.08-0.16) at 1 year, and 0.08 (95% CI, 0.05-0.12) at 2 years. At 3 months, a hyperopic shift of +0.36 diopters (P < .001) was observed and endothelial cell loss measured 33%.

CONCLUSION

Our findings provide real-world support that DMEK is an effective treatment for FED with respect to vision restoration, inducing a small hyperopic shift with an acceptable endothelial cell loss. Graft survival improved over time, suggesting a learning curve on a national level.

Fuchs endothelial corneal dystrophy: The vicious cycle of Fuchs pathogenesis

Fuchs endothelial corneal dystrophy (FECD) is the most common primary corneal endothelial dystrophy and the leading indication for corneal transplantation worldwide. FECD is characterized by the progressive decline of corneal endothelial cells (CECs) and the formation of extracellular matrix (ECM) excrescences in Descemet's membrane (DM), called guttae, that lead to corneal edema and loss of vision. FECD typically manifests in the fifth decades of life and has a greater incidence in women. FECD is a complex and heterogeneous genetic disease where interaction between genetic and environmental factors results in cellular apoptosis and aberrant ECM deposition. In this review, we will discuss a complex interplay of genetic, epigenetic, and exogenous factors in inciting oxidative stress, auto(mito)phagy, unfolded protein response, and mitochondrial dysfunction during CEC degeneration. Specifically, we explore the factors that influence cellular fate to undergo apoptosis, senescence, and endothelial-to-mesenchymal transition. These findings will highlight the importance of abnormal CEC-DM interactions in triggering the vicious cycle of FECD pathogenesis. We will also review clinical characteristics, diagnostic tools, and current medical and surgical management options for FECD patients. These new paradigms in FECD pathogenesis present an opportunity to develop novel therapeutics for the treatment of FECD.

Changing trends in penetrating keratoplasty indications at a tertiary eye care center in Budapest, Hungary between 2006 and 2017

AIM

To analyze the changing trends in penetrating keratoplasty (PKP) indications.

METHODS

This retrospective study included all patients with PKP between 2006 and 2017. Patients were classified using histological diagnoses. Our groups were as the following: pseudophakic or aphakic bullous keratopathy, regraft, acute necrotizing and ulcerative keratitis, keratoconus, Fuchs' dystrophy, corneal dystrophy other than Fuchs', corneal scar, other diagnoses and failed endothelial keratoplasty graft. Additionally, two different time-periods (2006-2012 and 2013-2017) were analysed.

RESULTS

Totally 1721 histological analyses of 1214 patients were available for review. The diagnoses were pseudophakic or aphakic bullous keratopathy in 487 (28.3%), regraft in 443 (25.7%), acute necrotizing and ulcerative keratitis in 313 (18.2%), corneal scar in 153 (8.9%), keratoconus in 140 (8.1%). Fuchs' dystrophy in 61 (3.5%), corneal dystrophy other than Fuchs' in 46 (2.7%), other diagnoses in 44 (2.6%) and failed endothelial keratoplasty graft in 34 (2.0%) cases. From the first to the second analysed time-period, incidence of acute necrotizing and ulcerative keratitis, corneal scar, Fuchs' dystrophy increased (P≤0.032 for all) and incidence of keratoconus significantly decreased (P=0.015).

CONCLUSION

Pseudophakic or aphakic bullous keratopathy is the leading indication for PKP, followed by regraft and acute necrotizing and ulcerative keratitis.

The learning curve for Descemet membrane endothelial keratoplasty performed by two experienced corneal surgeons: a consecutive series of 40 cases

PURPOSE

To describe the learning curve for Descemet's membrane endothelial keratoplasty (DMEK) in the Rotterdam Eye Hospital and to evaluate safety and visual outcome.

METHODS

This was a single-centre prospective study of 40 consecutive patients with Fuchs' endothelial dystrophy who underwent a DMEK procedure in the Rotterdam Eye Hospital. The performance of two corneal surgeons, each conducting their first series of 20 procedures, was examined with the cumulative summation test for the learning curve (LC-CUSUM). The surgical procedure was considered unsuccessful when >30% of the graft was not attached at any time during the first 12 postoperative weeks and a mixture of SF₆ (20%) and air (80%) had to be injected in the anterior chamber (rebubbling) to reattach the graft. Also assessed were visual outcome, intraocular pressure and peri- and postoperative complications.

RESULTS

In total, nine rebubbling procedures were performed in seven eyes. Following repeated rebubbling, two eyes did not achieve a satisfactory result and secondary surgery was required to restore visual function. Complications were usually manageable. The last 13 DMEK procedures (33%) of this series did not require rebubbling. After 3 months, 86% of the eyes had reached a Snellen visual acuity of 0.5 or more.

CONCLUSION

Together with the two surgeons' personal experience, the aggregate learning curve was considered to justify incorporation of Descemet membrane endothelial keratoplasty as a regular option of the standard of care for endothelial dysfunction in the Rotterdam Eye Hospital.

Graft Detachment After Descemet's Stripping Automated Endothelial Keratoplasty in Bullous Keratopathy and Fuchs Dystrophy

Descemet's stripping automated endothelial keratoplasty (DSAEK) is a surgical technique for corneal transplantation in case of corneal decompensation. One of the main complications is graft detachment (GD) recoverable with Air Re-bubbling (ARB). The aim of this retrospective, interventional case series was to identify factors related to this complication in eyes operated for bullous keratopathy (BK) and Fuchs dystrophy (FD). We considered one-hundred patients who underwent DSAEK for BK or FD between January 2016 and October 2017 at Department of Ophthalmology, Policlinico Universitario of Bari, Italy. Studied parameters included physiological and pathological anamnesis of both donors and recipients and properties of donor's lenticules and of the recipient's corneas. Data was analyzed using One-way ANOVA with Tukey post hoc test and Chi-square test with Odds Ratio (OR) calculation. We grouped patients according to diagnosis. GD occurred in 9 eyes affected by BK and 19 by FD (p=0.003, OR = 0.25, 95% CI, 0.098-0.62). It was recovered with ARB. In BK, ARB correlated to complicated cataract extraction (p=0.04, OR = 7.83, 95% CI, 1.28 - 47.98) and aphakia (p=0.026, OR = 54.38, 95% CI, 2.51 - 11.76). In FD, ARB was associated to donor's death for neoplasia (p=0.06, OR= 4.04, 95% CI, 1.06 - 15.37). No other differences were found. In conclusion, we could hypothesize that in FD patients, donor's cancer therapy may play a role on altered corneal fibroblast metabolism, activating a synergetic effect between chemotherapy and genetic alteration of FD, which may lead to an altered adhesion of donor's lenticule on recipient's stroma. In BK patients, complicated cataract extraction and aphakic status of recipients' eye may contribute to altered adhesion of donor's lenticule post-DSAEK.