Treatment Outcomes of Upside–Down Descemet Membrane Endothelial Keratoplasty

<b>Background</b>: To present the management of upside-down Descemet membrane endothelial keratoplasty (DMEK) with intraoperative optical coherence tomography (iOCT). <b>Methods</b>: We report the case of a 74-year-old woman who underwent DMEK for Fuchs' endothelial corneal dystrophy (FECD) of the right eye. Preoperative corrected distance visual acuity (CDVA) was 20/1500 (counting fingers [CF]), and the central corneal thickness (CCT) was 637 μm. No graft markings were made. Graft positioning was determined using iOCT. An improper graft position was suspected due to the lack of postoperative anatomical and functional improvements. The CDVA noted at that time was 20/1500 (CF), and the CCT was 708 μm. The graft was subsequently repositioned. This procedure was performed 33 days after the primary surgery. <b>Results</b>: The central corneal thickness and CDVA were 495 μm and 20/40 sc, respectively, at the final 18-month postoperative follow-up. <b>Conclusions</b>: Incorrect positioning of the transplanted corneal graft should be considered if no improvement is observed after DMEK. The learning curve significantly affects the occurrence of these complications. Graft repositioning, even 33 days after surgery, is associated with a favorable prognosis.