Endoart Prosthesis For Managing Refractory Corneal Edema Following Failed Penetrating Keratoplasty: A Case Series

To describe the anatomical and functional outcomes following EndoArt synthetic endothelial layer implantation in eyes with refractory corneal edema following failed penetrating keratoplasty (PKP), a particularly challenging population with limited alternative treatment options and elevated risks associated with repeat keratoplasty.

Single tertiary medical center, Department of Ophthalmology, Hadassah Medical Center, Hebrew University of Jerusalem, Israel. All procedures were performed by a single experienced corneal surgeon between July 2023 and July 2025.

This retrospective case series included ten consecutive eyes from ten patients with chronic corneal edema following failed PKP, refractory to medical management for at least three months. Primary outcome measures were central corneal thickness (CCT; μm), best-corrected visual acuity (BCVA; logMAR), and intraocular pressure (IOP; mmHg), assessed preoperatively and at final follow-up. CCT was measured using CASIA 2 swept-source anterior segment OCT. BCVA was obtained from medical records and measured by a certified optometrist. IOP was measured by Goldmann applanation tonometry. Adverse events including rebubbling, additional surgical interventions, IOP elevation, and infections were recorded.

Ten eyes (mean age 63.4 ± 19.3 years) were followed for a median of 35.4 weeks (IQR 22.9–73.5). Mean preoperative CCT decreased from 879.6 ± 182.4 μm to 718.6 ± 152.3 μm (mean reduction 154.6 ± 190.1 μm; P=0.169) in 7/10 eyes. Mean BCVA improved from 2.67 ± 0.54 to 2.10 ± 0.78 logMAR (P=0.128) in 9/10 eyes. Mean IOP decreased from 13.1 ± 8.1 to 11.4 ± 7.0 mmHg (P=0.502). Seven eyes (70%) required rebubbling (mean 0.70 procedures/eye). Additional interventions were performed in 7 eyes: cyclophotocoagulation (n=2), membrane peeling (n=2), keratectomy (n=1), implant suturing (n=1), and implant removal (n=1). One eye developed IOP elevation >21 mmHg. No infections occurred.

In this series of eyes with refractory corneal edema following failed PKP, EndoArt implantation demonstrated favorable anatomical outcomes with CCT reduction in most eyes, visual improvement or stabilization, and acceptable safety profile. However, the high rebubbling rate (70%) and need for additional interventions highlight the complexity of managing this high-risk population. Further studies with larger cohorts and longer follow-up are warranted.