Corneal Graft Rejection 10 Years After Penetrating Keratoplasty in the Cornea Donor Study

Purpose: The aim of this study was to assess the effect of donor and recipient factors on corneal allograft rejection and evaluate whether a rejection event was associated with graft failure. Methods: One thousand ninety subjects undergoing penetrating keratoplasty for a moderate risk condition (principally Fuchs dystrophy or pseudophakic corneal edema) were followed for up to 12 years. Associations of baseline recipient and donor factors with the occurrence of a rejection event were assessed in univariate and multivariate proportional hazards models. Results: Among 651 eyes with a surviving graft at 5 years, the 10-year graft failure (+/- 99% confidence interval) rates were 12% +/- 4% among eyes with no rejection events in the first 5 years, 17% +/- 12% in eyes with at least 1 probable, but no definite rejection event, and 22% +/- 20% in eyes with at least 1 definite rejection event. The only baseline factor significantly associated with a higher risk of definite graft rejection was a preoperative history of glaucoma, particularly when previous glaucoma surgery had been performed and glaucoma medications were being used at the time of transplant (10-year incidence 35% +/- 23% compared with 14% +/- 4% in eyes with no history of glaucoma/intraocular pressure treatment, P = 0.008). Conclusions: Patients who experienced a definite rejection event frequently developed graft failure raising important questions as to how we might change acute and long-term corneal graft management. Multivariate analysis indicated that previous use of glaucoma medications and glaucoma filtering surgery was a significant risk factor related to a definite rejection event.