Purpose: To study the histopathologic features of 19 corneal posterior lamellar grafts in eyes for which Descemet's stripping with automated endothelial keratoplasty (DSAEK) has failed. Design: Retrospective case series with clinicopathologic correlation. Participants: Nineteen cases of DSAEK failures undergoing repeat DSAEK or penetrating keratoplasty. Methods: The histopathologic results of posterior lamellar grafts (also termed DSAEK grafts), recipient corneas, or both from 19 cases of failed DSAEK were examined. Main Outcome Measures: Abnormalities in the DSAEK graft and in the interface between the recipient cornea and the DSAEK graft were assessed. Results: Histopathologic features in 19 failed DSAEK grafts revealed attenuation of endothelial cells (16 cases) and presence in the graft-host interface of fibrocellular tissue (11 cases), retained Descemet's membrane (5 cases), epithelial ingrowth (4 cases), or a combination thereof. Four DSAEK grafts had full-thickness corneal layers at 1 edge. Conclusions: Presence of interface material, such as fibrocellular tissue, retained Descemet's membrane, and epithelial ingrowth, are potential causes of dislocation. Endothelial attenuation was the most common finding in failed grafts. Decentered DSAEK grafts with full-thickness corneal layers at 1 edge are a potential cause for epithelial ingrowth. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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