1. Etiological and decision making factors for repeat DSAEK or PK in cases of failed Descemet stripping automated endothelial keratoplasty First and Presenting author: Jeewan S. Titiyal Co-authors: Manpreet Kaur, Tarun Arora, Rajesh Sinha Affiliation: RP Centre. AIIMS, New Delhi, India No author has any financial interests

2. Purpose To evaluate the causes for failure of Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) and study factors for deciding on the type of repeat keratoplasty (PK/DSAEK)

3. Methodology Type of study: Retrospective case series All cases of DSAEK performed between May 2012 to April 2014 at RPC, AIIMS (95 eyes)

4. Parameters evaluated Demographic profile Primary Indication for DSAEK surgery Postoperative course, and Secondary interventions

5. Outcome measures (at final visit) Best-corrected distance visual acuity (BCDVA) Intraocular pressure Graft clarity and Central corneal thickness

6. Results Mean (±SD) duration of follow up: 12.3 (±2.1) months Mean (±SD) preoperative central corneal thickness: 680 (±32.7) microns Of the total 95 DSAEK cases performed, 78 (82.1%) were successful at the final follow up However, 17 (17.9 %) grafts had failed at final follow up

7. Results (contd.) Primary etiology of cases with graft failure (17): o Pseudophakic bullous keratopathy (5) o Herpetic endothelitis (2) o Iridocorneal endothelial syndrome (1) o CHED (2) o Secondary scleral fixated IOL with endothelial decompensation (3) and o Peripheral anterior synechiae with secondary glaucoma (4)

8. Results (contd.) Of the 17 eyes with graft failure,  9 underwent repeat DSAEK including all cases with primary graft failure.  8 underwent full thickness penetrating keratoplasty

9. Factors for repeat penetrating keratoplasty Increased Central corneal thickness Peripheral anterior synechiae Secondary glaucoma

10. Results (contd.) Eight cases that underwent full thickness penetrating keratoplasty included: o Previous DSAEK with eccentric graft (2/4) o Previous SFIOL surgery (3/3) o CHED (1/2), ICE (1/1) and o Herpetic endothelitis (1/2)

11. Conclusion Primary graft failure was the leading cause of failure for DSAEK in our series Diseases associated with peripheral anterior synechiae, post-operative increased inflammations were associated with higher rate of DSAEK failure

12. Conclusion (contd.) All cases with primary graft failure could undergo successful repeat DSAEK surgery All cases with previously operated SFIOL, ICE, and half of cases with Herpetic endothelitis, CHED and Eccentric graft required a penetrating keratoplasty after failed DSAEK procedure