Spontaneous Corneal Clearance Despite Graft Detachment in Descemet Membrane Endothelial Keratoplasty

Purpose: To describe spontaneous recovery of corneal transparency in 2 cases with nearly complete graft detachment after Descemet membrane endothelial keratoplasty (DMEK). Design: Case series. Methods: In 2 patients with Fuchs endothelial dystrophy, DMEK was performed. Through a 3-mm clear corneal tunnel incision, the recipient Descemet membrane and its endothelium was stripped off from the posterior stroma. A 9.5-mm diameter organ-cultured Descemet roll was inserted into a recipient anterior chamber, positioned onto the posterior stroma, and secured by a complete air filling of the anterior chamber for 45 minutes. Results: At 1 month after uneventful DMEK, both transplanted corneas showed decompensation attributable to subtotal graft detachment. Unexpectedly, corneal transparency improved spontaneously, and at 3 months, both transplanted corneas had a normal pachymetry, despite persistent graft detachment. The patients' visual acuities improved to 20/50 (0.4) and 20/25 (0.8) at 3 months to 20/28 (0.7) and 20/20 (1.0), respectively at 9 months. Conclusions: Corneal clearance in the presence of a detached DMEK graft is not consistent with the current concept of endothelial keratoplasty, which requires an (attached) donor endothelial cell layer at the recipient posterior corneal surface. Endothelial transfer, migration, regeneration, or a combination thereof from either the donor or the recipient may explain the visual recovery. These observations suggest that a review of our approach to endothelial keratoplasty and the management of corneal endothelial disorders may be warranted.