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Is Khodadoust Line Common After Corneal Transplant Surgery?

A Khodadoust line is not considered a common finding after every corneal transplant, and researchers have not established a single rate for how many transplant recipients develop the line itself. It appears during endothelial graft rejection and is classically associated with penetrating keratoplasty, while reports describe it as rare after newer partial-thickness procedures. Studies have placed the three-year rate of immune rejection after DSAEK at about 4% to 22%, yet one study involving 54 eyes with confirmed DSAEK rejection found no Khodadoust lines among them. Another five-year study reported rejection episodes in 7.9% of DSEK eyes and 2.6% of DMEK eyes, which means only a smaller portion of patients undergoing these procedures would be at risk of showing the line. Despite being uncommon, a Khodadoust line is considered a definite sign of endothelial graft rejection and should be assessed promptly because it can advance across the cornea over several days or weeks.

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Is Khodadoust Line Common After Corneal Transplant Surgery?

A Khodadoust line is not considered a common finding after every corneal transplant, and researchers have not established a single rate for how many transplant recipients develop the line itself. It appears during endothelial graft rejection and is classically associated with penetrating keratoplasty, while reports describe it as rare after newer partial-thickness procedures. Studies have placed the three-year rate of immune rejection after DSAEK at about 4% to 22%, yet one study involving 54 eyes with confirmed DSAEK rejection found no Khodadoust lines among them. Another five-year study reported rejection episodes in 7.9% of DSEK eyes and 2.6% of DMEK eyes, which means only a smaller portion of patients undergoing these procedures would be at risk of showing the line. Despite being uncommon, a Khodadoust line is considered a definite sign of endothelial graft rejection and should be assessed promptly because it can advance across the cornea over several days or weeks.

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What Does a Corneal Rejection Line Look Like?

A corneal rejection line appears as a thin, curved band of inflammatory cells and deposits along the inner surface of the transplanted cornea. During a slit-lamp examination, it can look like a distinct border separating a clearer part of the graft from an area that has become swollen, cloudy, or hazy. The line commonly begins near the outer edge of the cornea and can move toward the center as the immune reaction affects more endothelial cells. Corneal swelling tends to be more noticeable on the side the line has already crossed, while the area ahead of it can still look relatively clear. Because the line sits deep inside the cornea and can be difficult to see without magnification, patients are more likely to notice related changes such as blurred vision, redness, light sensitivity, or discomfort rather than the line itself.

Other Symptoms That Can Appear During Corneal Graft Rejection

Beyond a visible rejection line, corneal graft rejection can cause blurred or suddenly reduced vision as inflammation and swelling interfere with the graft's clarity. Redness, sensitivity to light, eye pain, and irritation can develop as the immune response spreads through the transplanted tissue. During an eye examination, the doctor can also find corneal swelling, inflammatory deposits on the inner corneal surface, or inflammatory cells inside the front chamber of the eye. The symptoms can vary in intensity, so even a mild change in vision or unexplained redness deserves attention after transplant surgery. Patients who develop any combination of vision changes, redness, light sensitivity, or pain should contact their eye surgeon promptly since earlier treatment gives the graft a better chance of recovering.

Which Types of Corneal Transplants Have the Highest Rejection Risk?

Among commonly compared corneal transplant procedures, full-thickness penetrating keratoplasty has generally carried the greatest immune rejection risk because donor tissue replaces every layer of the cornea. One comparative study found that the cumulative chance of a rejection episode within two years was 18% after penetrating keratoplasty, compared with 12% after DSEK and only 1% after DMEK. DSEK and DSAEK still involve transplanted endothelial cells, so endothelial rejection and a Khodadoust line can occur, while DMEK tends to have the lowest rejection rate because it transfers a much thinner layer of donor tissue. Deep anterior lamellar keratoplasty preserves the patient's own endothelium, which means a classic endothelial rejection line is not expected, although rejection of the transplanted surface or stromal tissue can still develop. The risk rises further in repeat transplants and eyes with corneal blood vessels, glaucoma, prior graft failure, or ongoing inflammation, so the surgical method is not the only factor that determines who experiences rejection.

Why a Visible Rejection Line Needs Prompt Treatment

A visible rejection line signals that immune cells are actively attacking the donor endothelium, the layer responsible for pumping excess fluid out of the cornea and keeping it clear. As the line moves across the graft, the tissue behind it can become increasingly swollen and cloudy, which can cause a rapid decline in vision. Donor endothelial cells have very limited capacity to replace damaged cells, so delaying treatment raises the chance that the graft will not regain its previous clarity even after the inflammation is controlled. Corneal graft rejection accounts for about 30% of graft failures, although many episodes can be reversed when anti-inflammatory treatment begins before extensive cell loss develops. Anyone who notices new haze, redness, light sensitivity, pain, or reduced vision after a transplant should contact their eye surgeon promptly rather than waiting for the symptoms to improve on their own.

Frequently Asked Questions About Khodadoust Line

Can corneal graft rejection happen without a visible line?

Yes. Doctors can diagnose probable endothelial rejection when corneal swelling, inflammatory deposits, and inflammation inside the eye appear without a distinct rejection line, which is one reason a slit-lamp examination matters.

Can a corneal rejection line go away with treatment?

The line and related inflammation can fade when the rejection episode responds to treatment, with published reviews placing successful reversal rates between 50% and 90%. Some endothelial cells can still be permanently lost, so the graft's final clarity depends partly on how much damage occurred before the reaction was controlled.

Can corneal graft rejection happen years after surgery?

Yes. Rejection reaches its highest frequency during the first 18 months, but more than 10% of documented reactions have appeared four years after transplantation, and cases have been reported more than 20 years later. New redness, pain, light sensitivity, or reduced vision still deserves prompt attention even when the transplant was performed long ago.

Does one rejection episode mean the corneal graft has failed?

No. Many rejection episodes can be reversed, especially when treatment starts before extensive endothelial damage develops. A graft is classified as an immunologic failure when signs do not clear after two months of intensive treatment, while repeated episodes can gradually reduce the endothelial cell supply and raise the chance of later graft failure.

References

Advances in Corneal Graft Rejection. Current Opinion in Ophthalmology / Wolters Kluwer. https://pmc.ncbi.nlm.nih.gov/articles/PMC9290782/. Published July 1, 2021. Accessed July 16, 2026.

An Endothelial Rejection Line Following Descemet Stripping Automated Endothelial Keratoplasty. BMC Ophthalmology / Springer Nature. https://link.springer.com/article/10.1186/s12886-020-01575-x. Published July 29, 2020. Accessed July 16, 2026.

Corneal Graft Rejection. StatPearls / NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519043/. Updated June 11, 2023. Accessed July 16, 2026.

Corneal Grafting: What Eye Care Workers Need to Know. Community Eye Health Journal / International Centre for Eye Health. https://pmc.ncbi.nlm.nih.gov/articles/PMC2823110/. Published December 1, 2009. Accessed July 16, 2026.

Five-Year Graft Survival of Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Endothelial Keratoplasty and the Effect of Donor Sex Matching. Ophthalmology / Elsevier. https://pubmed.ncbi.nlm.nih.gov/29731147/. Published May 3, 2018. Accessed July 16, 2026.

Graft Rejection Episodes After Descemet Stripping With Endothelial Keratoplasty. Part One. Clinical Signs and Symptoms. British Journal of Ophthalmology / BMJ. https://pubmed.ncbi.nlm.nih.gov/19019931/. Published November 19, 2008. Accessed July 16, 2026.

Khodadoust Line. EyeRounds / University of Iowa Department of Ophthalmology and Visual Sciences. https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Khodadoust2/index.htm. Published June 4, 2024. Accessed July 16, 2026.

Risk of Corneal Transplant Rejection Significantly Reduced With Descemet's Membrane Endothelial Keratoplasty. Ophthalmology / Elsevier. https://pubmed.ncbi.nlm.nih.gov/22218143/. Published January 3, 2012. Accessed July 16, 2026.