Comparative Outcomes From 969 Endothelial Keratoplasties.

PURPOSE: The purpose of this study was to evaluate and compare clinical and visual outcomes, complications, and endothelial cell survival of different endothelial keratoplasty (EK) techniques-Descemet membrane endothelial keratoplasty (DMEK), preloaded DMEK (PL-DMEK), ultra-thin Descemet stripping automated endothelial keratoplasty (UT-DSAEK), and standard DSAEK-using real-world multicenter data. METHODS: This retrospective multicenter cohort study included patients undergoing EK across 11 corneal centers in Italy. Clinical and visual outcomes were collected at baseline, 3, 6, and 12 months, and at last follow-up. Donor graft characteristics and their impact on postoperative outcomes were analyzed. RESULTS: A total of 969 eyes were included. All EK techniques resulted in significant improvement in best-corrected visual acuity (BCVA). Although DMEK and PL-DMEK achieved better final BCVA, these groups had better baseline BCVA, and no significant differences in absolute BCVA recovery were observed among techniques, except for greater improvement with UT-DSAEK compared with DSAEK (P = 0.020). Rebubbling rates were significantly higher in DMEK and PL-DMEK (34.3% and 31.7%) than in UT-DSAEK and DSAEK (16.0% and 16.9%; P < 0.05). Endothelial cell density loss was greater in DSAEK (57.8%) and UT-DSAEK (53.8%) compared with DMEK (46.8%) and PL-DMEK (42.3%) (P < 0.001). Rejection rates did not differ significantly. Preservation media significantly influenced storage duration, BCVA, and pachymetry in analyses adjusted for baseline (ANCOVA P < 0.001), with Eusol, E-MEM + 6% dextran, and Tissue-C showing the most favorable outcomes. CONCLUSIONS: In this large multicenter real-world cohort, all EK techniques provided significant clinical benefit. Differences in visual outcomes, endothelial cell survival, and complication profiles support an individualized approach based on patient, donor, and surgical factors.