Changing Practice Patterns and Long-term Outcomes of Endothelial Versus Penetrating Keratoplasty: A Prospective Dutch Registry Study

PURPOSE: To compare graft survival, best-corrected visual acuity (BCVA), endothelial cell density (ECD), and refraction following penetrating keratoplasty (PK) vs endothelial keratoplasty (EK) for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK). DESIGN: Nonrandomized treatment comparison with national registry data. METHODS: All consecutive patients undergoing first keratoplasty for EED and PBK between 1998 and 2014 were analyzed, with a maximum follow-up of 5 years (mean +/- SD follow-up 39 +/- 20 months, range 0-60 months). Graft survival was analyzed using Kaplan-Meier survival curves and Cox regression analysis. BCVA, ECD, and refractive error were compared using linear mixed models. Main outcome measures were graft survival, BCVA, refraction, and ECD. RESULTS: A total of 5115 keratoplasties (PK = 2390; EK = 2725) were identified. Two-year graft survival following EK was lower compared with PK (94.5% vs 96.3%, HR = 1.56, P = .001). Five-year survival was comparable for EK and PK (93.4% vs 89.7%, HR = 0.89, P = .261). EK graft survival improved significantly over time while remaining stable for PK. One-year BCVA was better following EK vs PK (0.34 vs 0.47 logMAR, P <.001). Astigmatism was lower 1 year after EK vs PK (-1.69 vs -3.52 D, P <.001). One-year ECD was lower after EK vs PK (1472 vs 1859 cells/mm(2), P <.001). At 3 years, ECD did not differ between EK and PK. CONCLUSIONS: Long-term graft survival after EK and PK is high and comparable despite lower short-term survival for EK. EK graft survival improved over time, suggesting a learning curve. EK results in better BCVA, lower astigmatism, and similar long-term ECD compared with PK for FED and PBK.