ArticleBMC ophthalmology2026
Risk factors and survival analysis in high-risk penetrating keratoplasty: a retrospective cohort study in 220 patients.
Article in BMC ophthalmology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundHigh-risk penetrating keratoplasty (HRPK) is associated with significantly reduced graft survival compared to low-risk cases, with 5-year survival below 35% in developed countries. However, risk factors and outcomes may differ in developing regions where infectious and traumatic indications are more common. This study evaluates the 1- to 5-year graft survival rates and identified independent predictors of graft failure in HRPK from a tertiary center in China.
methodsWe performed a retrospective cohort study of 220 HRPK adult patients between December 2019 and December 2023, meeting standardized high-risk criteria including corneal neovascularization in two or more quadrants, re-transplantation, active inflammation, or combined procedures. Preoperative, intraoperative, and postoperative data were collected. Graft failure was defined as central corneal opacity of ≥ 4 mm or persistent corneal edema. Multivariable Cox regression analysis identified independent risk factors, and a prediction nomogram was created and validated via bootstrapping.
resultsGraft survival rates at 1, 3, and 5 years were 82.7%, 46.3%, and 34.7%, respectively. Graft failure occurred in 113 cases (51.36%) over the total follow-up period. Compared to non-failure cases, the failure group had higher rates of re-transplantation (53.1% vs. 38.3%, p = 0.039), peripheral anterior synechiae (63.7% vs. 47.7%, p = 0.024), and 4-quadrant neovascularization (34.5% vs. 17.8%, p = 0.036). Cox proportional hazards regression identified advancing age (HR 1.02 per year, 95% CI 1.01–1.04, p = 0.023), graft diameter ≥ 9 mm (HR 1.74, 95% CI 1.12–2.71, p = 0.02), and 4 quadrants of neovascularization (HR = 2.53, P < 0.01) as independent predictors of failure. Peripheral anterior synechia and re-transplantation were also associated with increased risk. The five-variable predictive nomogram showed moderate predictive performance for 3-year (AUC = 0.715) and 5-year (AUC = 0.770) survival rate, with strong calibration. Subgroup analysis indicated that mycophenolate mofetil was mostly administered to higher-risk patients; however, propensity-matched analysis demonstrated no significant survival advantage (50.0% vs. 50.0% failure rate, p = 0.856).
conclusionThis study identified advanced age, a large graft diameter (≥ 9 mm), and 4 quadrants of neovascularization as significant predictors of HRPK failure, with an especially elevated risk during the initial three postoperative years. Risk-based immunosuppressive strategies and close monitoring are essential to improving long-term outcomes in this high-risk population.
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