Descemet membrane endothelial keratoplasty and hybrid techniques for managing failed penetrating grafts

To report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet membrane automated endothelial keratoplasty (DMAEK) for failed penetrating keratoplasties (PKs).

Retrospective chart review of patients with a failed PK who were managed with DMEK or DMAEK surgery. Surgical technique, clinical findings, visual outcomes, and complications were documented and reported.

Six patients (mean age, 62 years; mean follow-up, 10 months) underwent DMEK (4 patients) or DMAEK (2 patients) under a failed PK. The graft diameter of the failed PK was 8 mm in all patients. In 3 patients, a 9-mm donor graft (DMAEK, 2; DMEK, 1) was used, whereas in the remaining patients, an 8-mm donor graft was chosen. Descemet membrane was stripped in 3 eyes because of the presence of Descemetic scarring. Four of the 6 eyes had a triple procedure. Two patients had preexisting open-angle glaucoma, whereas 1 patient developed postoperative steroid-response glaucoma. The median preoperative best-corrected visual acuity was 20/70, and postoperatively at 1, 3, and 6 months, 20/50, 20/40, and 20/30, respectively. The median donor endothelial cell density was 2801 cells per square millimeter, and at 3 and 6 months postoperatively, 1906 and 1880 cells per square millimeter, respectively. Three of the 4 DMEK eyes had peripheral graft detachment that attached successfully with 1 air injection. There was 1 primary failure that was managed with Descemet stripping endothelial keratoplasty.

DMEK or DMAEK can be considered to treat failed PKs. However, prior experience in performing these techniques in virgin eyes is recommended before use with a failed PK, which can present an additional challenge.