Management of Upside‑Down Descemet Membrane Endothelial Keratoplasty: A Case Series

Purpose: To present the management of upside‑down Descemet membrane endothelial keratoplasty (DMEK) following combined phacoemulsification with DMEK (phaco‑DMEK) in cases of Fuchs endothelial dystrophy (FED). Methods: This is a comparative interventional case series extracted from a prospective interventional case series (clinical outcome of DMEK combined with phacoemulsification for FED). We report five cases of upside‑down DMEK. Two cases of upside‑down DMEK were managed with re‑orientation and the other two with repeat DMEK. The 5th case underwent an initial re‑orientation and then a subsequent repeat graft. Graft re‑orientation and repeat surgery were performed 9–20 days after initial phaco‑DMEK. All the five cases were followed up over a 6‑month period, and the following outcomes were assessed: best corrected visual acuity (BCVA), contrast sensitivity (CS), central corneal thickness, endothelial cell density (ECD), and central macular thickness. Results: At the final 6‑month postoperative follow‑up, all the five cases achieved good outcomes in terms of BCVA and CS. Overall, the results were comparable to 32 control cases. One case of re‑orientation and the case of re‑orientation with subsequent repeat DMEK performed slightly less well than control cases in terms of postoperative ECD. Conclusions: Re‑orientation of the original DMEK scroll in cases of upside‑down DMEK can be a safe and cost‑effective alternative to repeat DMEK. If re‑orientation does not result in corneal deturgescence, a repeat DMEK may be done subsequently.