Older age and pseudophakia were independently associated with increased risk of low endothelial cell density, while diabetes was linked to lower ECD only in non-pseudophakic eyes, though the interaction between diabetes and lens status was not statistically significant.
Key Findings
Results
Diabetes mellitus was associated with lower endothelial cell density overall and increased odds of ECD falling below the 2000 cells/mm² threshold.
Diabetes was associated with a reduction of 106 cells/mm² in ECD (β = -106 cells/mm²; 95% CI -205 to -7)
Diabetes was associated with nearly doubled odds of ECD <2000 cells/mm² (OR=1.91; 95% CI 1.13 to 3.21)
37.1% of the 350 donors in the study had diabetes
The diabetic effect on ECD was only statistically significant in non-pseudophakic eyes in subgroup analyses
Results
Pseudophakia was independently associated with lower endothelial cell density and a higher likelihood of ECD falling below the 2000 cells/mm² threshold.
Pseudophakia was associated with OR=2.88 (95% CI 1.80 to 4.63) for ECD <2000 cells/mm²
22.8% of donors were pseudophakic
The association was described as consistent across both continuous and binary modeling of ECD
Generalised estimating equations were used to account for within-donor clustering
Results
Older age was independently associated with lower endothelial cell density and increased likelihood of ECD falling below the 2000 cells/mm² threshold.
Each additional year of age was associated with OR=1.05 (95% CI 1.03 to 1.07) for ECD <2000 cells/mm²
Mean donor age in the study was 62.8 years
The association was consistent across both continuous and binary modeling of ECD
Age was assessed alongside diabetes and pseudophakia as independent variables in multivariate models
Results
The effect of diabetes on endothelial cell density appeared to be modified by pseudophakia status, with the diabetic association present only in non-pseudophakic eyes.
In stratified models, diabetes was linked to lower ECD only in non-pseudophakic eyes
Formal statistical testing for interaction between diabetes and lens status was not significant
Potential effect modification by pseudophakia was assessed using stratified models
The authors note this subgroup finding should be interpreted cautiously given the non-significant interaction test
Methods
The study analyzed 681 donor corneas from 350 individuals over a 10-year period using specular microscopy for ECD measurement.
Data were collected retrospectively from Rabin Medical Center between 2014 and 2024
ECD was measured centrally using Konan CellChek specular microscopy, which quantifies ECD based on manual marking of central endothelial cell centres
A commonly used reference threshold of <2000 cells/mm² was used as the binary outcome
Generalised estimating equations were used to account for within-donor clustering, as multiple corneas could come from the same donor
Baseline variables included age at donation, sex, diabetes status, and lens status
What This Means
This research suggests that the health of the inner layer of corneal tissue donated for transplantation — measured by endothelial cell density (ECD) — is significantly affected by donor age, whether the donor had an artificial lens implanted (pseudophakia), and to some extent by diabetes. The study examined records from 681 donated corneas collected over 10 years. Donors who were older or who had previously undergone cataract surgery with lens replacement had notably higher chances of having low endothelial cell counts, which can affect the success of corneal transplants. Specifically, each additional year of age increased the odds of low ECD by about 5%, and having an artificial lens nearly tripled those odds.
Diabetes also appeared to be associated with lower endothelial cell counts overall, but this effect was only observed in donors who still had their natural lens. In donors with an artificial lens, the relationship between diabetes and lower ECD was not apparent. However, the formal statistical test for this difference between groups was not significant, meaning this finding should be interpreted cautiously and may warrant further investigation in larger studies.
This research suggests that eye banks and transplant programs may benefit from carefully considering donor age, lens status, and diabetes when evaluating the quality of donated corneal tissue. Since low endothelial cell density can reduce the viability of a donor cornea for transplantation, understanding which donor characteristics are associated with lower counts could help improve the screening and selection of donor tissue, ultimately improving outcomes for patients receiving corneal transplants.
Shavit I, Salminis Linzen S, Shvaiger A, Tiosano A, Livny E, Dotan A. (2026). Relationship between age, pseudophakia, diabetes mellitus and endothelial cell density in corneal donor tissue: a 10-year retrospective study.. BMJ open ophthalmology. https://doi.org/10.1136/bmjophth-2025-002618