Long-Term Clinical Outcomes of nDSAEK and Machine Learning-Based Prediction of Graft Survival in Corneal Endothelial Decompensation

Purpose: To evaluate long-term outcomes of non-Descemet stripping automated endothelial keratoplasty (nDSAEK) in low-vision patients with corneal endothelial decompensation (CED), and to develop a machine-learning framework for predicting graft failure. Methods: This retrospective study included 114 eyes (Fuchs’ and non-Fuchs’ etiologies) treated with nDSAEK. Best-corrected visual acuity (BCVA), endothelial cell density (ECD), and complications were assessed over a long-term follow-up. Linear mixed-effects models (LMM) analyzed ECD kinetics. An XGBoost model using 10 clinical features was constructed to predict graft failure, interpreted via SHapley Additive exPlanations (SHAP) analysis. Results were compared against established endothelial keratoplasty benchmarks. Results: The median follow-up was 41.50 months (IQR: 25.65– 55.75 months). Mean BCVA improved significantly from 1.80 logMAR baseline to 1.20 logMAR at 6 months, remaining stable thereafter. At 3 years, mean ECD was 1724 ± 279 cells/mm 2 .,Subgroup stratification demonstrating a 3-year cumulative ECD loss of 37.9% in the Fuchs’ group compared to a significantly higher long-term depletion rate of 45.3% in the non-Fuchs’ group. LMM analysis showed that femtosecond laser-assisted nDSAEK (FS-nDSAEK) significantly improved long-term ECD maintenance over manual dissection. The predictive framework yielded longitudinal risk-discrimination capability, demonstrating a time-dependent area under the ROC curve (AUC) of 0.917 (95% CI: 0.819– 1.000) at 12 months, 0.920 (95% CI: 0.823– 1.000) at 24 months, and 0.880 (95% CI: 0.765– 0.995) at 36 months, driven by 15 confirmed graft failure events within the 114-eye cohort. SHAP analysis identified FS assistance and preoperative ECD as key protective factors. Compared to literature benchmarks, nDSAEK demonstrated visual and anatomical stability demonstrated visual and anatomical trends that align with historical DSAEK cohorts. Conclusion: nDSAEK offers stable long-term visual and anatomical outcomes for CED. The integration of AI frameworks offers an exploratory framework for individualized prognostic screening, though further external validation is required before direct clinical integration. Keywords: non-descemet stripping automated endothelial keratoplasty, corneal endothelial decompensation, post-cataract surgery, endothelial cell density, long-term graft survival