Artificial substitutes for Descemet's membrane - corneal endothelium complex: state of the art

Descemet's membrane (DM) serves as the specialized basement membrane that supports corneal endothelial cells (CECs), which actively maintain corneal transparency and fluid balance. In diseases like Fuchs' dystrophy and pseudophakic bullous keratopathy, damage to DM and the endothelial cell layer leads to corneal edema and significant visual impairment, often necessitating surgical intervention. Traditional endothelial keratoplasty techniques require donor tissue yet many countries have shortages which limit accessibility. The risk of endothelial keratoplasty failure is generally low, but eyes with prior glaucoma filtration surgery, ocular trauma, or multiple graft rejection episodes can have a significantly increased risk of graft failure. This review examines current strategies for DM replacement, focusing on natural and synthetic biomaterials developed for cultured CEC delivery or as cell-free implants. While natural materials offer excellent biocompatibility, they often lack sufficient mechanical strength and durability. Synthetic polymers provide improved structural control, with emerging designs, such as EndoArt, showing promise in clinical use despite the absence of active pump function. Future materials may aim to replicate both the architecture and physiological role of the native DM-corneal endothelium complex. Hybrid constructs and stimuli-responsive systems are being explored as next-generation alternatives that may reduce dependence on donor grafts and expand therapeutic options for endothelial dysfunction.