Secondary DMEK for Poor Visual Outcome After DSEK Donor Posterior Stroma May Limit Visual Acuity in Endothelial Keratoplasty

Purpose: To describe the clinical outcome of a secondary Descemet membrane endothelial keratoplasty (DMEK) to manage poor visual outcome after Descemet stripping endothelial keratoplasty (DSEK). Methods: Three eyes of 3 patients that underwent DSEK for Fuchs endothelial dystrophy showed fluctuating and/or poor visual outcome ranging from 20/80 (0.25) to 20/40 (0.5). In a secondary procedure, 16-22 months after the initial DSEK, the DSEK graft was removed and replaced by a DMEK graft. The clinical outcome was evaluated by comparing the pre- to postoperative best-corrected visual acuity (BCVA), Pentacam imaging, and biomicroscopy. Results: All secondary DMEK procedures were uneventful. Three months after secondary DMEK, all eyes had a BCVA of 20/25 (0.8) or better. Pentacam analysis showed a virtually stable anterior corneal curvature in all cases, but among cases, the transplant exchange induced variable refractive change at the posterior corneal surface. Conclusion: To manage DSEK cases with poor visual outcome, secondary DMEK may be a feasible procedure potentially resulting in full visual rehabilitation, as in primary DMEK. The presence of donor posterior stroma in DSEK, but not in DMEK grafts, may be a major factor in limiting the final BCVA in endothelial keratoplasty.