Long-Term Endothelial Outcomes and Dislocation Risks in Small Versus Large Grafts for Descemet's Stripping Endothelial Keratoplasty.

BACKGROUND This study compared the clinical outcomes of small-graft (7.0 mm <diameter ≤8.0 mm) versus large-graft (8.0 mm <diameter £9.0 mm) diameters in patients with bullous keratopathy (BK) undergoing Descemet's stripping endothelial keratoplasty (DSEK). MATERIAL AND METHODS In this single-center, retrospective comparative study, 62 patients were divided into small-graft (n=28) and large-graft (n=34) groups based on the graft diameter. Best-corrected visual acuity (BCVA), endothelial cell density (ECD), endothelial cell loss (ECL) rate, graft transparency, and complications were evaluated at scheduled follow‑ups at 1, 3, 6, and 12 months postoperatively. RESULTS At 12 months, the ECL rate was significantly lower in the large-graft group (20.07±8.17%) than in the small-graft group (24.34±7.20%), with a mean difference of -4.27% (95% confidence interval [CI]: -8.23% to -0.07%, P=0.035). BCVA improvement and graft transparency were comparable between groups, with no significant difference in the 12-month graft survival rate (small-graft group: 96.43% vs large-graft group: 94.12%, P=0.788). However, the large-graft group (32.35%) had a significantly higher incidence of graft dislocation compared to the small-graft group (10.71%, P=0.043). The incidence rates of secondary glaucoma and graft rejection were comparable between groups. CONCLUSIONS For BK patients undergoing DSEK, the use of larger grafts was associated with better long-term ECD preservation but also a higher observed incidence of graft dislocation. The selection of graft size should therefore be individualized, balancing the potential for enhanced endothelial survival against the elevated risk of postoperative dislocation.