THE “PACMAN” DMEK: SUCCESSFUL VISUAL REHABILITATION DESPITE A LARGE GRAFT TEAR DURING DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY

To report a case of Descemet membrane endothelial keratoplasty (DMEK) complicated by an intraoperative graft tear resulting in a “Pacman-like” configuration, highlighting that even markedly damaged grafts can lead to excellent visual and endothelial outcomes.

Department of Ophthalmology, Hospital de Santa Maria, Lisbon, Portugal.

A 75-year-old woman with Fuchs endothelial corneal dystrophy presented with progressive morning blurring and decreased visual acuity in her right eye (best-corrected visual acuity [BCVA] 0.3). She was pseudophakic and otherwise ophthalmologically stable. DMEK with 20% sulfur hexafluoride (SF6) tamponade was performed for endothelial dysfunction. During graft manipulation, a large radial tear occurred, resulting in a semicircular “Pacman-shaped” defect in the donor lenticule. Despite the irregular configuration, the graft was successfully unfolded, centered, and attached to the host stroma. Postoperatively, the patient adhered to strict supine positioning. At the first postoperative week, the graft was well attached with minimal nasal edema corresponding to the site of the tear. Corneal transparency was progressively restored, and central corneal thickness decreased from 592 µm preoperatively to 539 µm at three months. At three months postoperatively, BCVA improved to 0.5+, intraocular pressure remained stable at 10–12 mmHg, and the cornea was completely transparent with a well-adhered lenticule. No signs of immune rejection, graft detachment, or secondary failure were observed.

Even in cases of large Descemet membrane tears leading to an irregular or “Pacman-shaped” graft, successful DMEK outcomes can be achieved with proper centration and adhesion. Surgeons should not immediately abandon the procedure after a major graft tear, as endothelial function and visual rehabilitation can still be excellent. This case illustrates that perseverance and meticulous handling during DMEK can salvage complex cases and result in clear corneas with meaningful visual improvement.