Descemet Membrane Endothelial Keratoplasty and Hybrid Techniques for Managing Failed Penetrating Grafts

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