Corneal clearance and central endothelial cell repopulation despite graft detachment after Descemet membrane endothelial keratoplasty

Objective: Descemet membrane endothelial keratoplasty (DMEK) is the gold standard procedure for treatment of primary corneal endothelial disorders. Graft detachment is a frequent complication of DMEK, which often requires re-operation or re-bubbling. However, several cases of spontaneous corneal clearance despite graft detachment after DMEK have been reported. The underlying mechanisms of this phenomenon are poorly understood. We report three cases of corneal clearance after graft detachment in patients with Fuchs endothelial dystrophy and provide a review of the literature. Methods: An 81-year-old and a 69-year-old phakic patient as well as a 56-year-old pseudophakic patient with Fuchs endothelial dystrophy underwent Triple-DMEK and DMEK, respectively. All three patients presented postoperatively with blurred vision due to an almost complete detachment of the graft, as shown by slit-lamp photography and anterior segment optical coherence tomography (OCT). Results: Without additional intervention, gradual corneal clearance and presence of endothelial cells on the posterior recipient's stroma were observed in all patients three months postoperatively. Increase in endothelial cell density, decrease in central corneal thickness (CCT), recovery of corneal transparency, and improvement of visual acuity were documented in all patients.Conclusions: Our findings support the theory of corneal clearance after Descemet membrane endothelial transfer (DMET) ("free-floating" donor Descemet graft in the recipient anterior chamber after descemetorhexis). Further understanding on endothelial homeostasis might lead to innovative approaches in handling endothelial disorders