Outcomes Of Repeat Endothelial Keratoplasty: A 20-Year Single-Centre Experience Comparing Descemet Membrane Endothelial Keratoplasty And Descemet Stripping Endothelial Keratoplasty

Repeat endothelial keratoplasty remains a technically demanding procedure with limited long-term outcome data, particularly in the context of modern Descemet membrane endothelial keratoplasty (DMEK). This study aims to evaluate the long-term visual, endothelial, and surgical outcomes of repeat endothelial keratoplasty over a 20-year period at a tertiary referral centre, and to compare the efficacy and safety of DMEK versus Descemet stripping endothelial keratoplasty (DSEK) in this challenging operative setting.

This retrospective consecutive case series was conducted at the Corneal Service, King's College Hospital NHS Foundation Trust, London, United Kingdom - a major tertiary referral centre serving a large and ethnically diverse South London population. All repeat endothelial keratoplasty procedures performed between 2006 and 2026 were captured from a prospectively maintained institutional surgical database, encompassing cases performed by multiple corneal surgeons across a 20-year audit period.

Consecutive repeat endothelial keratoplasties (N=78) were identified. Demographics, indication, prior glaucoma surgery, donor metrics and intraoperative trauma score were recorded. Visual acuity, intraocular pressure and endothelial cell counts were collected pre‑operatively and at standard post‑operative intervals. Comparative analyses between repeat DMEK and DSEK used appropriate parametric/non‑parametric tests; survival analysis assessed graft viability in FED eyes.

Seventy‑eight eyes (66 second, 11 third, 1 fourth graft) were included; DMEK n=19, DSEK n=59. Overall mean pre‑op VA improved from 1.65 ± 0.79 logMAR to 0.82-0.97 logMAR across follow‑up with statistically significant gains at all timepoints versus baseline (p<0.001 early; sustained at later visits). Donor mean endothelial cell count (ECC) was 2633±186 cells/mm². In the Fuch's Endothelial Dystrophy subgroup, DMEK demonstrated superior early and sustained visual acuity versus DSEK. Rebubbling occurred in 6/78 (7.7%) overall. Endothelial cell density declined in both groups with no significant difference in percentage ECL at 12–60 months. Mean graft survival in FED eyes was similar (DMEK 69.38 vs DSEK 68.36 months; p=0.778).

Repeat endothelial keratoplasty provides clinically meaningful and durable visual rehabilitation. DMEK achieves superior visual outcomes in FED patients undergoing repeat grafting, consistent with its superiority in primary cases, without a significant increase in graft failure risk. Despite inherently greater surgical complexity in repeat cases, DMEK graft survival is equivalent to DSEK. These data support the adoption of DMEK as the preferred technique for repeat endothelial keratoplasty in appropriate candidates at experienced centres, and provide important benchmarking data for patient counselling and surgical planning.