Descemet’s membrane endothelial keratoplasty with scraping without descemetorhexis (DMEK-SWD) in a failed penetrating keratoplasty

Sep 28, 2026

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Introduce a novel approach for secondary failed penetrating keratoplasty (PK): Descemet’s membrane endothelial keratoplasty with endothelial scraping and without descemetorhexis (DMEK-SWD), reported through two clinical cases. In a prospective single-center series, patients with prior PK developed endothelial decompensation with decreased visual acuity and increased central corneal thickness. DMEK-SWD used a 7.5-mm cell scraper and a standardized no-touch graft insertion; postoperative antibiotics and steroid injections were given. Both cases achieved improved visual acuity, reduced CCT, maintained graft attachment, and showed endothelial cell density gains. The pilot study supports feasibility with preliminary findings.

LanguageEnglish

CategoryHealthcare

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Abstract

Introduction

American Journal of Ophthalmology Case Reports 41 (2026) 102499 Contents lists available at ScienceDirect American Journal of Ophthalmology Case Reports journal [homepage:](homepage: www.ajocasereports.com/)[ www.ajocasereports.com/](homepage: www.ajocasereports.com/) | Descemet’s membrane endothelial keratoplasty with scraping without descemetorhexis (DMEK-SWD) in a failed penetrating keratoplasty
Alexander Wallacea, Mohit Parekhb, Sabrina Vaccaroc,* , Francesco Semeraroc,d, Vito Romano c,d
a Manchester University NHS Foundation Trust, Manchester, UK
b Schepens Eye Research Institute, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USAc Department of Molecular and Translational Medicine, University of Brescia, Italy
d Eye Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 15, 25123, Brescia, Italy | | | | --- | --- | --- | | A R T I C L E I N F O | | A B S T R A C T | | Keywords: Cornea Surgery Endothelium DMEK
PK
Endothelial decompensation | | Purpose: To introduce a novel treatment for a secondary failed penetrating keratoplasty (PK), termed Descemet’s Membrane Endothelial Keratoplasty with endothelial scraping and without descemetorhexis (DMEK-SWD), through the presentation of two clinical cases.
Observations: In this prospective, single-center case series, two patients with previous PK for keratoconus developed endothelial decompensation, presenting with decreased visual acuity (Patient A: counting fingers; Patient B: 0.8 logMAR) and increased central corneal thickness (A: 735 μm; B: 653 μm). DMEK-SWD was performed using a 7.5-mm cell scraper through the temporal port to mechanically remove the host endothelium. A pre-stripped 7.5-mm DMEK graft was inserted using a standardized no-touch technique. Postoperative management included subconjunctival injections of gentamycin and dexamethasone. Graft attachment was maintained in both cases, although Patient B required single rebubbling procedure.
Postoperative graft endothelial cell density (ECD), measured from confocal imaging (HRT3-RCM Cell Count), was 1,125 cells/mm2 at 12 months in Patient A and 1,544 cells/mm2 at 8 months in Patient B. At final follow-up (A: 18 months; B: 8 months), both patients showed improved best-corrected visual acuity (A: 0.2 logMAR; B: 0 logMAR) and reduced CCT (A: 496 μm; B: 505 μm).
Conclusions and importance: This pilot study demonstrates the feasibility of DMEK-SWD in treating failed PK, with a mean graft clearance time of 1.5 weeks for the two cases analyzed. The technique may represent a promising alternative to repeat full-thickness transplantation and supports further investigation in larger cohorts. Given the very small sample size and the incomplete availability of endothelial cell count data, these findings should be regarded as preliminary. | 1. Introduction Late secondary endothelial failure is a leading indication for reintervention after penetrating keratoplasty (PK).1 Descemet’s Membrane Endothelial Keratoplasty (DMEK) has been established as an effective treatment for PK endothelial failure (DMEK-on-PK) over PK regrafting, given lower rejection risk, better vision, and fewer suture-related complications.2–4 Additionally, DMEK achieves superior outcomes compared to other endothelial keratoplasty (EK) procedures, such as Descemet stripping automated endothelial keratoplasty (DSAEK)(DSAEK-on-PK), in terms of recovery time and vision.5,6 However, detachment and rebubbling rates with DMEK-on-PK remains a concern.4 Technical factors likely contribute. In failed PK, corneal haze impairs visualization during descemetorhexis, increasing the risks of incomplete DM removal and DM-tag formation, which can create an uneven bed predisposing to graft malapposition, decentration, and detachment.2,7,8 Under normal conditions, descemetorhexis creates a smooth surface for the DMEK adh

FAQs

What problem does DMEK-SWD aim to address in patients with failed penetrating keratoplasty?

DMEK-SWD targets late secondary endothelial failure after penetrating keratoplasty by treating endothelial decompensation following a failed PK.

How is DMEK-SWD performed in the reported cases?

A 7.5-mm cell scraper is used through a temporal port to mechanically remove the host endothelium, and a pre-stripped 7.5-mm DMEK graft is inserted using a standardized no-touch technique without descemetorhexis.

What outcomes were observed after surgery in the two cases?

Both patients showed improved best-corrected visual acuity, reduced central corneal thickness, and maintained graft attachment; one patient required single rebubbling. Endothelial cell density increased by follow-up measurements.

Sep 28, 2026

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