Repeat penetrating keratoplasty in patients with keratoconus

Purpose: To determine factors influencing penetrating corneal graft survival in patients receiving repeat grafts in the same eye after a failed first graft for keratoconus. Design: Large cohort study from a national register of corneal grafts, in which data were recorded prospectively and analyzed retrospectively. Follow-up extended to 23 years. Participants: Follow-up was available for 229 regrafts performed in 177 eyes of 173 patients. Regrafts were performed more than once in 16 eyes. Methods: Corneal graft survival was analyzed using KaplanMeier survival plots and Cox proportional hazards regression, clustered by patient. Main Outcome Measures: Graft survival. Results: Graft survival was significantly worse (P<0.001) for second (n = 176) and third or greater grafts (n = 20), compared with first grafts for keratoconus (n = 4871). KaplanMeier survivals at 1, 5, and 15 years postgrafting were 88%, 69%, and 46% for second grafts, and 65%, 49%, and 33% for third and subsequent grafts, respectively (P<0.001). Risk factors associated with graft failure of repeat grafts in multivariate analysis were the geographic location of surgery ("center"; P = 0.04), failure of the previous graft within 10 years of surgery (P = 0.02), recipient age at graft <60 years (P = 0.04), occurrence of rejection episodes (P = 0.007), and corneal neovascularization postoperatively (P = 0.007). Conclusions: Repeat corneal grafts in eyes originally grafted for keratoconus showed better survival when the previous graft had survived <10 years, surgery was performed at a favorable location, the recipient was <60 years old at grafting, and graft rejection and neovascularization were circumvented. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.