Objectives: To report real-world long-term survival of primary penetrating keratoplasty (PK) in the United States and analyze risk factors associated with failure. Design: Retrospective longitudinal cohort study using a large commercial insurance database. Participants: Ten million patients enrolled in the database from 2011 to 2017 were identified using Current Procedural Terminology codes for PK. Methods: Kaplan–Meier survival analysis was performed to determine failure rate and risk factors impacting graft outcomes. Results: Five hundred and ninety-six primary PKs were identified. The 3-year survival was 78% (confidence interval [CI]: 73%–82%), 5-year survival was 76% (CI: 70%–80%), and 7-year survival was 73% (CI: 66%–79%). Conclusion: This study demonstrated a significantly lower 5-year success rate for primary PK performed for all causes than previously published case series in the United States.
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