A double Descemet's stripping endothelial keratoplasty on a penetrating keratoplasty

A patient with keratoconus underwent a penetrating keratoplasty (PK) in his right eye. This failed after 12 years following phacoemulsification surgery. A Descemet's stripping endothelial keratoplasty (DSEK) was carried out which failed and detached after 4 months. Subsequently, a second DSEK was performed which failed after 2 months but remained attached. This graft was retained in the cornea and a third DSEK button was placed without removing the failed DSEK graft. The cornea cleared well and patient's vision was 6/9 at 18 months postsurgery. Optical coherence tomography showed the two DSEK grafts closely applied to each other and to the recipient cornea. Stripping a failed DSEK graft performed for a previous failed PK carries the risk of internal dehiscence of the PK graft-host junction. This was avoided by placing the second DSEK graft on the failed previous DSEK graft with good visual outcome indicating that this option can be clinically considered.