Advanced Age, Large Graft Size Risk Factors for Graft Failure in High-risk PK

Advanced age, graft diameter ≥9 mm and four quadrants of neovascularization were identified as independent risk factors for graft failure in high-risk corneal transplants. Early identification and proactive management of high-risk features may help improve long-term graft survival in this vulnerable patient population, according to authors of a recent study. Photo: Aaron Bronner, OD. Click image to enlarge. The five-year graft survival rate for high-risk penetrating keratoplasty is below 35% in developed countries. However, risk factors and outcomes may differ in developing regions, where infectious and traumatic indications are more common. In a recent study, Chinese researchers evaluated one- to five-year graft survival rates and identified independent predictors of graft failure in high-risk cases and found that advanced age, graft diameter ≥9mm and four quadrants of neovascularization (NV) were identified as independent risk factors for failure, with the steepest decline occurring within years one to three after the transplant. The findings were reported in BMC Ophthalmology.A total of 220 adult patients who met standardized high-risk criteria including corneal neovascularization in two or more quadrants, re-transplantation, active inflammation or combined procedures were included. Preoperative, intraoperative and postoperative data were collected. Graft failure was defined as central corneal opacity of ≥4mm or persistent corneal edema.This study identified advanced age, graft diameter ≥9mm and four quadrants of neovascularization as independent risk factors for graft failure in high-risk corneal transplants. The graft diameter ≥9mm is likely due to proximity to limbal vasculature, anatomical instability and elevated risk of secondary glaucoma, according to the authors. “Additional research suggests that large grafts, frequently necessary in severe infections to avoid recurrence or in re-transplantation requiring excision of opaque host tissue, are associated with poor outcomes,” they wrote in their paper. “We recommend limiting graft size (7.5mm to 9mm) where feasible, optimizing postoperative anti-inflammatory and IOP management.”The association with age may reflect the nature of this study cohort, with 42% aged over 60 years. Additionally, re-transplantation made up 50% of the cohort, compounding the risk, according to the researchers. “High IOP, epithelial abnormalities, endothelium decompensation, as well as potentially inconsistent follow-up adherence may also contribute to age-related failure,” they wrote.The one-year, three-year and five-year graft survival rates were 82.7%, 46.3% and 34.7%, respectively. “Our study confirms that re-transplantation is a significant risk factor for graft failure,” the authors wrote in their paper. “This is likely due to immune sensitization, memory T-cell activation, disruption of anterior chamber immune privilege and coexisting corneal NV.” In this cohort, prior graft rejection accounted for 63% of initial graft failures among re-transplantation cases, underscoring the need for intensified perioperative immunosuppression in these patients. “Based on these findings, we recommend enhanced preoperative adherence counseling and individualized immunosuppression, (e.g., triple therapy) for patients with re-transplantation, multi-quadrant NV, PAS or advanced age.”Click here for the journal source. Ii L, Luo J, Feng Z, et al. Risk factors and survival analysis in high-risk penetrating keratoplasty: a retrospective cohort study in 220 patients. BMC Ophthalmol. January 21, 2026. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.