Endothelial keratoplasty after failed penetrating keratoplasty: an alternative to repeat penetrating keratoplasty.

To analyze graft survival of endothelial keratoplasty (EK) under a previous failed penetrating keratoplasty (PK) compared to repeat PK. Retrospective, comparative case series. Analysis involved consecutive patients who underwent either a repeat PK or EK under PK, after failed PK, whose primary surgical indication was pseudophakic bullous keratopathy at a single tertiary center. Clinical data and donor and recipient characteristics were recorded from our prospective cohort from the Singapore Corneal Transplant Study. Main outcome measure was graft survival up to 5 years follow-up. We included a total of 113 eyes that underwent a repeat PK (n = 81) or EK under a failed PK (n = 32). Cumulative graft survival probabilities comparing repeat PK with EK under PK were at 91.9% vs 96.2% (1 year), 82.6% vs 91.6% (2 years), 66.8% vs 86.4% (3 years), and 51.3% vs 86.4% up to 5 years follow-up, respectively (log-rank P value = .013). Multivariate Cox regression analysis was performed, which adjusted for: age, sex, risk factors for graft failure (corneal neovascularization, ocular surface disease, glaucoma, active corneal inflammation, anterior synechiae), donor endothelial cell count, and repeat donor size. Repeat PK was a significant risk factor for graft failure compared to performing an EK under PK (hazard ratio: 10.17; 95% CI 1.10-93.63; P = .041). In our study of eyes with bullous keratopathy, endothelial keratoplasty under a previously failed PK provided better graft survival outcomes than repeat PK, adjusting for potential confounders and risk factors for graft failure.