To describe various endothelial migration healing patterns after Descemet membrane endothelial keratoplasty (DMEK), and to determine the contribution of the donor and host endothelium in the clearance of a transplanted cornea.

Nonrandomized, prospective clinical study.

In a total of 150 consecutive eyes that underwent DMEK (ie, transplantation of an isolated Descemet graft, for Fuchs endothelial dystrophy), re-endothelialization patterns were studied. Of these eyes, 36 showed a “stromal gap” between the “descemetorhexis edge” and the graft, or (partial) graft detachment. Endothelialization patterns of the host posterior stroma were documented at 1, 3, 6, 9, 12, and 24 months after surgery with Pentacam imaging, specular microscopy, optical coherence tomography, confocal microscopy, and slit-lamp biomicroscopy.

Complete corneal clearance was seen in 28 of 36 eyes (78%) with a stromal gap, or (partial) detachment, progressing from the periphery toward the center; and 27 of 34 eyes (79%) with normal visual potential reached a visual acuity of ≥20/40 (≥0.5) or better. In 3 eyes that had the Descemet graft implanted upside-down, a “reversed corneal clearance pattern” was observed (ie, persistent edema where the graft was attached), while the area overlying the detachment cleared. One case that had a “descemetorhexis” performed without endothelial graft implantation showed persistent stromal edema.

The presence of donor endothelium in the recipient anterior chamber may be required for endothelial migration and/or recovery of corneal clarity. Re-endothelialization may be associated with massive endothelial migration and some form of cell signaling to draw donor endothelial cells toward the recipient posterior stroma (“homing”).