Preparation of Donor Tissue in Descemet Membrane Endothelial Keratoplasty (DMEK): Impact of Pseudophacic Donor Status on Clinical Outcomes

PURPOSE: To evaluate whether the lens status of donor eyes (phakic vs. pseudophakic) influences graft preparation, graft handling, and postoperative outcomes in Descemet membrane endothelial keratoplasty (DMEK). METHODS: Retrospective analysis of 1171 DMEK cases, comparing phakic (n = 870) and pseudophakic (n = 301) donor eyes. Graft preparation characteristics, surgical complications, and postoperative outcomes including endothelial cell count (ECC), visual acuity (VA), central corneal thickness (CCT), rebubbling and repeat keratoplasty rates were assessed with a three-year follow-up. RESULTS: Pseudophakic donor tissue was significantly more difficult to prepare, with higher rates of tissue tears and need for manual dissection (both p < 0.001), though preparation times did not differ significantly. These challenges were linked to increased repeat keratoplasty risk (p = 0.041) and lower postoperative ECC (p = 0.047 at 1 year), while CCT and VA remained comparable. Intraoperative difficulties in graft manipulation occurred more frequently during implantation in the pseudophakic group (p = 0.14) and were associated with a significantly lower endothelial cell count after one year (p = 0.08) as well as a significantly higher risk of graft failure (p = 0.028). Overall, rebubbling (37% vs. 26%, p < 0.001) and repeat keratoplasty (12% vs. 7%, p = 0.045) were significantly more frequent in the pseudophakic group. Despite these complications, both groups showed comparable and significant visual improvement (p < 0.001). CONCLUSION: Although pseudophakic donor tissue increases the technical complexity of DMEK resulting in significantly higher rates of rebubbling and repeat keratoplasty, successful grafts yield comparable visual outcomes to those from phakic donors. Pseudophakic corneas should therefore be considered a valuable additional donor source in times of tissue scarcity, provided that preparation and implantation are performed by experienced surgeons.