Purpose: To evaluate the safety and efficacy of artificial endothelial layer (EndoArt ® ) implantation in patients with chronic corneal edema with or without prior endothelial keratoplasty at a tertiary referral center. Methods: This retrospective, non-comparative study reviewed medical records of consecutive patients who underwent EndoArt ® (EyeYon Medical, Israel) implantation between December 2024 and November 2025. Patients with chronic corneal oedema and a minimum 12-week follow-up were included; eyes with prior penetrating keratoplasty were excluded. Primary outcome was central corneal thickness (CCT) measured by anterior segment optical coherence tomography. Secondary outcomes included best-corrected distance visual acuity (BCDVA), intraocular pressure, resuturing/rebubbling rates, and complications. Results: Nine eyes of nine patients were included (mean age: 72± 17 years; 55% female). Four patients (44%) had previous failed endothelial keratoplasty. Mean follow-up was 27± 14 weeks. Mean baseline CCT decreased significantly from 780± 106μm 95% CI: 710.0, 861.3μm to 574± 107μm 95% CI 502.8, 643.1μm, postoperatively (adjusted for implant thickness), representing a 35% reduction (265± 89 μm; 95% CI: − 338.8 to − 190.8μm; p< 0.01). Mean BCDVA improved from 2.28± 0.54 LogMAR 95% CI 1.87, 2.71 LogMAR to 1.16± 0.79 LogMAR 95% CI 0.55, 1.78 LogMAR. Three patients (33%) achieved postoperative BCDVA of ≤ 0.5 LogMAR. Two patients (22%) required re-suturing; no rebubbling was performed. No endophthalmitis, inflammatory reactions, or chronic intraocular pressure elevation occurred. Conclusion: Artificial corneal endothelial implant was associated with significant reduction in corneal thickness (35%) and improvements in visual acuity in eyes with chronic endothelial dysfunction, with or without prior endothelial keratoplasty. The procedure was feasible in complex eyes with prior failed endothelial keratoplasty and glaucoma drainage devices. EndoArt ® represents a viable donor-tissue-independent alternative for high-risk patients in whom traditional keratoplasty carries a guarded prognosis. Plain Language Summary: What is already known on this topic: Endothelial keratoplasty (DSAEK/DMEK) is effective for endothelial failure but remains dependent on donor tissue availability.Repeat keratoplasty and complex eyes (e.g. prior graft failure, glaucoma drainage devices) have higher risks and more guarded prognosis.There is a global mismatch between corneal tissue supply and demand, driving interest in donor-independent alternatives.EndoArt is a synthetic posterior corneal “artificial endothelial layer” designed to restore corneal deturgescence via a passive barrier mechanism without donor tissue.Most published EndoArt data to date are in high-risk/complex cohorts, with limited evidence in patients with more regular anatomy and/or mixed histories of prior EK. What this study adds :EndoArt implantation produced a significant mean CCT reduction of ~35% (780 μm to 574 μm after adjusting for implant thickness) over a mean follow-up of ~27 weeks.Mean BCDVA improved from 2.28 to 1.16 logMAR, with 33% achieving 0.5 logMAR or better.The procedure was feasible in eyes with and without prior failed endothelial keratoplasty, including complex cases with glaucoma drainage devices and prior vitrectomy.Reintervention was limited to re-suturing in 22%, with no rebubbling required; two eyes were partially attached at last follow-up under observation.No endophthalmitis, inflammatory reactions, or chronic IOP elevation occurred during follow-up. How this study might affect research, practice or policy :Supports EndoArt as a practical donor-tissue-independent option for selected patients with chronic corneal oedema, particularly high-risk or repeat-graft scenarios.Suggests a higher-risk subgroup for attachment issues (vitrectomised eyes/limited tamponade), informing surgical planning and follow-up (e.g. use of multiple transfixing sutures and AS-OCT–guided adjustment).Provides real-world tertiary-centre data to inform patient counselling on expected anatomic improvement and realistic visual outcomes in comorbid eyes.Strengthens the rationale for larger prospective studies comparing EndoArt with standard EK, including longer-term outcomes and clearer selection criteria.Highlights the potential role of donor-independent implants in pathways where tissue access is delayed or prognosis for traditional keratoplasty is poor. Keywords: artificial endothelial layer, EndoArt ® , corneal oedema, endothelial keratoplasty, synthetic corneal implant, DMEK/DSAEK failure, bullous keratopathy
Levy et al. (Mon,) studied this question.