Early Postoperative Endothelial Cell Density Predicts Graft Survival After Keratoplasty: A Systematic Review and Meta-Analysis

Long-term graft clarity after corneal transplantation depends on sustained endothelial survival, yet the prognostic role of early postoperative endothelial metrics has not been clearly synthesized. We therefore reviewed longitudinal clinical evidence and quantitatively summarized the relationship between early postoperative endothelial status and later endothelial failure-related graft failure across common keratoplasty techniques. Overall, lower endothelial reserve measured in the early postoperative period consistently aligned with higher subsequent failure risk, with suggestive signals that risk may rise steeply below certain low-density ranges, while a minority of grafts can remain clear despite very low counts. Limited data also indicate that some endothelial morphological features may add prognostic value beyond cell density. These findings support using early postoperative endothelial assessment as part of practical risk stratification and follow-up planning, alongside measures aimed at preserving endothelial reserve to help extend graft longevity.