Risk Factors For Early Versus Late Graft Dislocation After Endothelial Keratoplasty

To identify systemic, ocular, and surgical predictors of early vs late after DMEK or DSAEK and evaluate the impact of dislocation timing on complications and visual acuity.

Single tertiary academic center. 

Retrospective analysis of 1,355 eyes undergoing endothelial keratoplasty from 2013 to 2022. Graft dislocation was categorized as no dislocation, early rebubbling (≤1 week), or late rebubbling (>1 week). Data included systemic/ocular history, preoperative visual acuity, operative details, postoperative complications and visual acuity, and donor factors. Multivariable statistical analysis assessed outcomes including risk factors for graft dislocation, postoperative complications, and visual acuity outcomes over 12 months.

Of 1,355 (531 DMEK and 824 DSAEK) eyes meeting inclusion criteria, 126 (9.3%) had late and 67 (4.9%) had early rebubbling. DMEK was more likely to dislocate late, whereas DSAEK dislocated earlier (p=0.0004). Use of air was linked to late dislocation, whereas SF6 increased early risk (p<0.0001). Donor diabetes, especially insulin dependent group, increased dislocation risk (p=0.0004). Early/late rebubbling was associated with higher rates of persistent detachment (p<0.0001), graft failure (p=0.0002), edema (p<0.0001), and worse vision during the first postoperative months (p<0.0001).

EK graft dislocation is influenced by surgical and donor factors. DMEK grafts dislocate later, and DSAEK earlier. Air was associated with late dislocation, and SF6 with early dislocation. Donor diabetes status increased risk of dislocation. Dislocation is also linked to persistent detachment, graft failure, edema, and delayed visual recovery.