Descemet Membrane Endothelial Keratoplasty (DMEK) Under Previous DMEK for Secondary Endothelial Graft Failure

Purpose: To describe an alternative treatment option for secondary Descemet membrane endothelial keratoplasty (DMEK) graft failure, using a second DMEK graft without primary graft removal ("DMEK under-DMEK"). Methods: A 72-year-old patient with pseudophakic bullous keratopathy in the left eye underwent an 8.25-mm second DMEK under an 8.5-mm failed DMEK because of previous graft rejection and subsequent secondary failure. Results: Corrected distance visual acuity improved from 0.2 (decimal scale) before surgery to 0.56 (best visual potential due to concomitant preexisting macular damage) from the first month after surgery and up to sixth-month follow-up. Complete corneal transparency was achieved from the first postoperative day and remained until the end of the follow-up. Pachymetry returned to normal values within the first month. No intraoperative or postoperative complications were observed. Conclusions: A second DMEK graft without peeling or removing the first DMEK graft is an alternative treatment option for DMEK graft secondary failure. This approach is able to achieve full anatomical and functional restoration of the prefailure status. This technique allows a second graft surgery to be easier, faster, and with less intraoperative risks (as a result of a potential difficult host descemetorhexis). Future studies with larger samples and a longer follow-up are necessary to confirm the short and long-term outcomes of this new DMEK under DMEK approach.