A 65-year-old male patient with history of keratoconus and penetrating keratoplasty (PK) over 30 years ago developed corneal oedema subsequent to the graft failure in his left eye with best corrected visual acuity (BCVA) of counting fingers. He had an eccentric 7.5 mm penetrating keratoplasty, which made repeat full thickness keratoplasty with a larger donor graft a high risk for rejection. He also had a mild cataract. Therefore, he was offered Descemet membrane endothelial keratoplasty (DMEK) on failed PK combined with cataract surgery using standard keratometry of 43.5D and a hydrophobic acrylic intraocular lens. After inserting the intraocular lens, while the anterior chamber was filled with a cohesive viscoelastic device, we performed a Descematorhexis within the graft-host junction. Care was taken not to expose posterior stromal strands during Descematorhexis. After a thorough washout of the viscoelastic device a 7.25 mm Descemet membrane graft was delivered and secured on the stroma within the old penetrating keratoplasty, using an intracameral injection of 50% Sodium Hexafluoride (SF6) gas. Cyclopentolate 1% eye drops were used immediately after the injection of gas to prevent pupillary block, since he has had no peripheral iridotomies. The patient was advised to comply with supine posture for a minimum of 2 days and was given antibiotic-steroid combination drops qds for a month, G. Cyclopentolate 1% tds for a week and Tb. Acetazolamide 250 mg sustained release for 3 days post-surgery. One week post-operatively the cornea appeared oedematous with inferior detachment of DMEK graft (Figure 1(a)). Re-bubbling with air was performed at the slit lamp via 5 o'clock paracentesis,   the patient was started on Acetazolamide 250 mg slow release tablets for 3 days and advised to maintain a supine posture for a minimum of 2 days and ideally as long as the air was present in the anterior chamber. One week later, he was noticed to have persistent inferior graft detachment and corresponding corneal oedema (Figure 1(a)); therefore, the second re-bubbling was performed at the slit lamp in the same fashion. His cornea remained oedematous inferiorly at 4 weeks due to persistent inferior Descemet membrane detachment (Figure 1(a)) despite two subsequent re-bubblings. Careful inspection of his anterior segment OCT (AS-OCT) revealed a ridge on the posterior surface of the graft-host junction infero-nasally (Figure 1(a)), which was the probable cause of his recurrent inferior Descemet membrane detachment. To manage this complication, he underwent DMEK suturing in the theatre under subtenon anaesthesia. The detached graft was repositioned, using intracameral injection of air. Based on the extent of the DMEK detachment three radial full thickness 10-0 nylon interrupted sutures were placed in the inferior cornea to hold the graft in place. The needle passed through the host cornea and exited from the graft cornea. Care was taken not to tear the detached Descemet with unnecessary needle movement in the anterior chamber (Supplemental Video 1) (Figure 1(b)). One week post-operatively, his AS-OCT confirmed complete attachment of the DMEK graft with clear appearance of posterior protuberance (Figure 1(c)). Four weeks later, the corneal sutures were removed at the slit lamp and no further sutures were needed. Following this, his medications switched to G. Dexamethasone 0.1% qds for 2 months followed by bd for long-term. His corneal oedema resolved (Figure 2(a) and (b)) and his visual acuity gradually improved. Eight months from DMEK, his cornea was clear, and his unaided visual acuity was 20/63 with BCVA of 20/32 using rigid gas permeable contact lens (best spectacle corrected vision was 20/60 and best contact lens corrected vision was 20/32 before PK graft failure).
The patient provided written informed consent to publish all related medical data, images and videos.