Descemet Membrane Endothelial Keratoplasty: Evolving Surgical Techniques and Contemporary Clinical Outcomes – A Narrative Review

Abstract

Objective: To synthesize contemporary developments in endothelial keratoplasty, outlining the evolution from penetrating keratoplasty (PK) and DSEK/DSAEK to Descemet Membrane Endothelial Keratoplasty (DMEK), while summarizing modern surgical refinements, clinical outcomes, complication patterns, and emerging innovations.
Methods: A narrative review was conducted using PubMed and Scopus (January 2010–February 2026). Search terms included DMEK, DSAEK/UTDSAEK, posterior lamellar keratoplasty, DSO/DWEK, endothelial cell loss, graft detachment, preloaded grafts, and longterm outcomes. Eligible sources comprised randomized trials, cohort studies, large case series, systematic reviews, and techniquefocused reports. Findings were synthesized thematically due to heterogeneity in study designs and outcome measures.
Result: Across the literature, DMEK consistently provides the fastest visual recovery and best optical outcomes among endothelial keratoplasty techniques, with many eyes achieving ≥20/25 vision postoperatively. Early endothelial cell loss is substantial but stabilizes over time. Surgical innovations including preloaded P3 tissue, endotheliumin delivery, standardized notouch unfolding maneuvers, and orientation stamps have reduced intraoperative manipulation and improved reproducibility. Graft detachment remains the most frequent early complication, influenced by low early postoperative intraocular pressure, older age, diabetes, and Fuchs endothelial corneal dystrophy; however, timely rebubbling typically preserves longterm graft function. Despite progressive endothelial attrition, DMEK maintains high graft survival and low rejection rates over longterm followup.
Conclusion: Today, DMEK is considered the gold standard for endothelial replacement due to its exceptional optical quality and minimal immunologic risk. Looking forward, bioengineered endothelial constructs, cell‑based therapies, and tissue‑efficient graft formats hold promise for expanding global access and reducing reliance on donor tissue.