EndoArt: Indications, Mechanism of Action, Outcomes, and Complications

Diseases of the corneal endothelium are among the most common indications for corneal transplantation worldwide. Despite the significant advances achieved with lamellar techniques such as Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) and particularly Descemet Membrane Endothelial Keratoplasty (DMEK), which have markedly reduced rejection rates, the risk of early graft failure remains substantial in certain patient groups-such as individuals with disruptions of the blood-aqueous barrier or glaucoma patients with drainage implants. At the same time, the global shortage of donor corneas, especially in many regions of Africa and Asia, intensifies the need for a readily applicable, immunologically non-reactive artificial endothelial substitute. Endoart (EyeYon Medical, Ness Ziona, Israel) is an innovative option for high-risk eyes in which conventional transplantation is insufficient or repeatedly unsuccessful. In addition, this endothelial keratoprosthesis could help alleviate the persistent shortage of donor tissue in regions with limited access to corneal grafts. Key advantages include the relatively simple surgical procedure, the possibility of implantation even in cases with complex anterior segment anatomy, and the absence of allogeneic immune reactions. In contrast, a wide range of potential complications has been recognized. Poor adhesion can often be corrected by repeated gas injections or fixation sutures, whereas other complications-such as retroprosthetic membrane formation, suboptimal visual recovery, persistent peripheral edema, inadequate corneal dehydration, or recurrent band keratopathy-are considerably more challenging to manage and may necessitate explantation of the device. Risk factors for unfavorable attachment, including defects of the iris-lens diaphragm or irregularities of the posterior corneal surface, have already been identified. Current research aims to further delineate predictors of unfavourable outcomes following implantation of this prosthesis.