Endophthalmitis Following Artificial Endothelial Keratoplasty (Endoart®)

EndoArt® is a synthetic artificial endothelial implant designed to treat corneal oedema. It offers the advantage over conventional keratoplasty of eliminating rejection risk. Clinical studies have shown marked oedema reduction with improved vision and pain relief, although relatively high detachment and rebubbling rates have been reported. We report a case of endophthalmitis, related to the full-thickness anchoring sutures used to attach the device to the posterior cornea.

Cornea and External Diseases Department at Moorfields Eye Hospital, London, United Kingdom.

We present a case of a 76-year-old male with bilateral PK in the 1970s for keratoconus, complicated by recurrent rejection and endothelial failure. In the left eye, further procedures were performed (repeat PK, DSAEK, a third PK), which failed due to rejection. EndoArt® was offered in June 2025 as an alternative. Preoperative visual acuity (VA) was 1/60 with CCT of 746 µm; postoperatively, his BCVA improved to 6/18 and CCT to 581 µm after 3 months showing significant improvement in corneal transparency. Five months post-op, he developed a corneal infiltrate in one of his full-thickness anchoring corneal sutures, progressing rapidly to hypopyon and endophthalmitis despite intensive topical treatment. 

Given the reported detachment rate, the use of full-thickness anchoring sutures during implantation are required which usually remain for few months. In this case, four sutures were placed and it was the plan to remove them all at six months post-op. The rapid progression of endophthalmitis in this case was related to the presence of the full-thickness sutures. The patient later underwent intravitreal injection of antibiotics and received a tectonic penetrating keratoplasty due to melting and perforation.

Full-thickness anchoring sutures required for EndoArt® increase the risk of microbial keratitis and endophthalmitis, and early removal should be considered. Maintaining topical antibiotic treatment until suture removal would be recommended in all these cases.