Ocular surface & cornea — endothelial graft
DMEK: endothelial keratoplasty of the cornea
DMEK (Descemet Membrane Endothelial Keratoplasty) is the reference technique for treating diseases of the corneal endothelium. Less invasive than a full-thickness graft, it replaces only the failing cell layer and allows for rapid visual recovery with one of the lowest rejection risks among corneal grafts.
Why the corneal endothelium is essential
The corneal endothelium is a single-cell layer of about 500,000 cells lining the inner surface of the cornea. Its role is to maintain corneal transparency by continuously pumping out the water that seeps into it. When it no longer performs this function, the cornea swells, becomes opaque, and vision gradually deteriorates to the point of permanent discomfort.
Unlike other ocular tissues, endothelial cells do not regenerate. Once lost, they are lost for good. The normal cell density is about 2,500 cells/mm². Below 500 cells/mm², the risk of corneal decompensation becomes major. Grafting is the only curative treatment.
Indications — when is DMEK necessary?
Fuchs’ dystrophy
Fuchs’ endothelial dystrophy is the main indication for DMEK. It affects about 4% of the adult population after age 40 and progresses through gradual loss of endothelial cells. The first symptoms are blurred vision in the morning that improves during the day (nocturnal oedema), light halos, and then permanent vision loss. The decision to operate is guided by best-corrected visual acuity, central pachymetry and corneal densitometry.
Post-operative endothelial decompensation
Previous ocular surgery — cataract surgery in particular — can weaken the endothelium and precipitate its decompensation, especially in patients who had an underlying Fuchs’ dystrophy. It is the second most frequent indication in the large published series.
Other indications
Iridocorneal endothelial syndrome (ICE syndrome), posterior polymorphous corneal dystrophy (PPCD), pseudophakic bullous keratopathy, endothelial trauma.
DMEK, DSAEK, penetrating keratoplasty: what’s the difference?
There are three families of corneal grafts depending on the depth of the replaced tissue.
| Technique | Grafted tissue | Thickness | Recovery | Rejection rate |
|---|---|---|---|---|
| DMEK | Descemet membrane only | ~15 µm | 1 to 3 months | 1–3 % |
| DSAEK | Descemet + posterior stroma | 100–150 µm | 3 to 6 months | 5–10 % |
| Penetrating keratoplasty (PK) | Full cornea | full thickness | 12 to 24 months | 10–20 % |
DMEK offers the fastest visual recovery and the lowest rejection rate. It is today the technique of choice for isolated endothelial conditions in specialised centres. This is precisely what a systematic review co-authored by Dr Tourabaly confirms, comparing the long-term outcomes of lamellar endothelial keratoplasty with those of penetrating keratoplasty (Cornea, 2023).
How the procedure works
DMEK is performed under local or general anaesthesia in the operating theatre of the Clinique Victor Hugo (Paris 16). The procedure lasts about 45 to 60 minutes.
- Preparation of the graft: the donor’s Descemet membrane is detached and prepared by the surgeon
- Access through a 2.5 to 3 mm microincision at the limbus
- Removal of the diseased endothelium (Descemet stripping)
- Introduction of the graft, rolled into a scroll, via an injector into the anterior chamber
- Unrolling and centring of the graft through fluid manipulation
- Air injection to press the graft against the recipient cornea
No sutures are needed. The incision is self-sealing.
Post-operative course
D0 – D1: lying flat on the back for 1 to 2 hours after the procedure to help the graft adhere via the air bubble. Vision still very blurred.
Week 1: vision gradually less blurred, mild photophobia. Antibiotic and anti-inflammatory (cortisone) eye drops.
1 month: most patients regain functional vision. The graft is in place and the cornea gradually deswells.
3 months: main visual recovery completed. No contact sports for 4 weeks. No eye rubbing.
Expected results
DMEK is one of the corneal graft procedures with the best results documented in the international literature.
- 94% of eyes reach a corrected visual acuity ≥ 20/40 at 3 months
- Excellent visual acuity maintained at 5 years and beyond
- Low rejection rate — in the range of 1 to 3% at 5 years in Fuchs’ dystrophy
- Graft survival of about 93% at 5 years documented in large multicentre series
- Visual recovery significantly faster than with DSAEK or penetrating keratoplasty
The work published by Dr Tourabaly in the British Journal of Ophthalmology confirms that the thickness and regularity of the graft directly influence the quality of visual recovery and post-operative optical aberrations.
PATIENT TESTIMONIALS
Reviews from patients who had a corneal graft
Authentic reviews published on Google Maps: over 1,000 reviews · 4.9/5.
I was fortunate to be cared for by this professional and attentive doctor for a corneal graft in September 2021. Reassured by his support, I have since not hesitated for a second to follow him to his private practice. Warmly welcomed by the secretary in this pleasant and easily accessible space, I recommend this centre!!
We have known Doctor Tourabaly since the Quinze-Vingts hospital, where he performed a partial corneal graft on my husband. Complete success. We follow him to Cachan. Very professional and attentive to the patient.
Frequently asked questions
Scientific references
Publications by Dr Tourabaly:
- Tourabaly M, Chetrit Y, Provost J et al. Influence of graft thickness and regularity on vision recovery after endothelial keratoplasty. British Journal of Ophthalmology. 2020. PMID 31848210.
- Lemaitre D, Tourabaly M, Borderie V, Dechartres A. Long-term Outcomes After Lamellar Endothelial Keratoplasty Compared With Penetrating Keratoplasty for Corneal Endothelial Dysfunction: A Systematic Review. Cornea. 2023;42:917–928. DOI 10.1097/ICO.0000000000003240 PMID 37185592.
- Tourabaly M, Knoeri J, Georgeon C et al. Long-term results and refractive error after cataract surgery with a scleral incision in eyes with deep anterior lamellar keratoplasty. Cornea. 2021
- Tourabaly M. Review of the Literature: Surgery Indications for Fuchs’ Endothelial Corneal Dystrophy. Journal of Clinical Medicine. 2025;14(7):2365. DOI 10.3390/jcm14072365 PMID 40217815.
General references:
- Baydoun L et al. Long-Term Outcome After Bilateral DMEK for Fuchs Endothelial Corneal Dystrophy. Cornea. 2024;43(6):726–733. PMID 37702586
- De Herdt L et al. DMEK: 10-year clinical outcomes and graft survival. BMJ Ophthalmol. 2022;7(Suppl 2):A15–16. PMID 37282710
- Anshu A, Price MO, Price FW. Risk of corneal transplant rejection significantly reduced with DMEK. Ophthalmology. 2012;119(3):536–540. PMID 22218143
- Teubert S et al. Ten-Year Follow-Up After DMEK. Cornea. 2024. PMID 39476369
Book an appointment for a pre-operative assessment
The pre-operative consultation includes specular microscopy (endothelial cell density), pachymetry, a corneal OCT and a complete assessment of the ocular surface. It is available in Cachan (94) and Paris 13.