PK-SMART: Penetrating Keratoplasty With Sutureless Membrane Artificial Endothelial Replacement Technique. Report of the First Three Clinical Cases

To describe penetrating keratoplasty with sutureless membrane artificial endothelial replacement technique (PK-SMART), a surgical procedure that allows for combined penetrating keratoplasty (PK) and EndoArt (EndoArt, EyeYon Medical, Israel) implantation in high-risk eyes for graft failure.

Three consecutive patients with failed PK and a history of multiple ocular surgeries underwent repeat PK combined with implantation of a synthetic endothelial replacement membrane. The implant was positioned within a stromal lamellar pocket of the donor cornea before graft transplantation, without the need for transcorneal sutures or postoperative gas tamponade. Outcome measures included corrected distance visual acuity (CDVA), graft clarity, central corneal thickness, and device adherence.

At 6 months, all corneal grafts were clear with complete EndoArt adhesion. Preoperative CDVA ranged from light perception to hand motion in 2 eyes. Postoperative CDVA improved to hand motion, 20/400, and 20/100, respectively. Central corneal thickness decreased in all patients, from 803 to 578 μm, from 975 to 587 μm, and from 761 to 548 μm. No postoperative complications were observed, including implant detachment requiring rebubbling.

PK-SMART simultaneously addresses stromal opacities through PK and endothelial dysfunction through artificial endothelial replacement. The technique is suited for complex, high-risk eyes in which standalone EndoArt implantation cannot resolve stromal opacities and is associated with a high risk of device detachment. Central corneal clarity was restored in all our patients, with quantifiable improvements in visual function. Larger studies with extended follow-up will be required to confirm the long-term safety and efficacy of this procedure.