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The aim of this study was to evaluate clinical outcomes and graft survival in a large patient cohort up to 10 years after Descemet membrane endothelial keratoplasty (DMEK) based on surgical indication and Fuchs endothelial corneal dystrophy (FECD) severity. Methods:The cohort in this retrospective study included 750 eyes that underwent DMEK for FECD (86%), bullous keratopathy (BK, 9%), and other indications (5%). Based on the modified Krachmer grading, 186 eyes (29%) had moderate FECD (Krachmer grade 3-4) and 440 eyes (68%) had advanced FECD (Krachmer grade 5-6). Main outcome measures were best-corrected visual acuity (BCVA), central corneal thickness, endothelial cell density (ECD), endothelial cell loss (ECL), postoperative complication rate, and graft survival. Results:The mean 10-year BCVA was 0.08 6 0.28 logMAR (n = 96), and the BCVA remained stable between 5 and 10 years postoperatively (all P . 0.05). The mean ECL at 5 and 10 years was 56% 6 17% (n = 460) and 66% 6 14% (n = 96), respectively (P , 0.05). The 10-year graft survival rate for the total cohort was 0.85 (95% confidence interval, 0.82-0.89). BCVA and ECD differed at 1 to 5 years between eyes with different surgical indications (all P , 0.05), and FECD eyes had higher graft survival compared with BK eyes (0.90 vs. 0.60, P = 0.001). Moderate FECD eyes had better BCVA, ECD, and graft survival outcomes than advanced FECD eyes (all P , 0.05). Minor graft detachment (P = 0.04) and lower donor ECD (P = 0.01) were related to lower 10-year ECD.Conclusions: Long-term outcomes and graft survival after DMEK were better in FECD eyes than BK eyes and were also related to FECD disease severity. Eyes operated for moderate FECD showed the highest graft survival probability and excellent longterm outcomes.

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