CME Increases Odds of Graft Rejection Post-Endothelial Keratoplasty by 11-fold

There could be a possible immunologic link between cystoid macular edema and endothelial graft rejection episodes, new research suggests. In the study, the average time between the onset of CME and the occurrence of rejection was 11.5 ±14.1 months. Photo: Christopher Kuc, OD. Click image to enlarge. Graft failure following endothelial keratoplasty is most commonly caused by immunologic rejection, with known risk factors including concomitant glaucoma, AfroAmerican origin and discontinuation of topical steroids. A new study proposes that postoperative development of cystoid macular edema (CME), as well as the presence of glaucoma and older age, may also contribute to endothelial graft rejection. Their findings were recently published in the journal Cornea.The single-center retrospective case review study evaluated 731 eyes undergoing Descemet membrane endothelial keratoplasty (DMEK) and 2,815 eyes undergoing Descemet stripping automated keratoplasty (DSAEK). Researchers assessed how the following risk factors influenced graft rejection: recipient age, sex, indication for surgery, type of keratoplasty, glaucoma and development of CME. The mean follow-up duration was 49.5 ±37.9 months. The incidence of graft rejection was 2.9% and 4.0% among patients who received DMEK and DSAEK, respectively. The odds of rejection significantly increased with patients’ age, with an odds ratio of 2.17. Specifically, the average age in the graft rejection cohort was 67.8 years vs. 64.1 years in patients whose grafts weren’t rejected. Eyes that developed graft rejection also had a higher prevalence of glaucoma (29.9% vs. 13.1%) and CME (19.4% vs. 2.1%). The mean time from the onset of CME to the occurrence of rejection was 11.5 ±14.1 months.“Eyes with CME had 11 times higher odds of postoperative rejection compared with those without CME,” which translates to an odds ratio of 11.09, the researchers reported in their paper. However, the reasons for this association remain uncertain, they noted, as “it is unclear whether postoperative inflammation can lead to both CME and rejection, or whether graft rejection itself can be the primary trigger for an inflammatory response resulting in CME.”On the other hand, the following factors appeared to have no effect on graft rejection: sex, indication for surgery, type of endothelial keratoplasty and combination of the procedure with phacoemulsification.These findings should be interpreted with caution, the authors explained, since its retrospective design spans nearly two decades and the logistic regression model demonstrated only a modest explanatory power, “meaning that the included variables account for only a small share of the variability in rejection.” Nonetheless, they concluded, “preoperative glaucoma, younger recipient age and the development of postoperative CME should heighten clinical vigilance for the potential onset of immunologic graft rejection following endothelial keratoplasty.”Click here for the journal source. Spena R, Bovone C, Taloni A, et al. Risk factors for graft rejection following endothelial keratoplasty: focus on cystoid macular edema. Cornea. April 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.