Purpose: To report the clinical outcomes of 3 Descemet membrane endothelial keratoplasty (DMEK) grafts, in which an upside down DMEK graft orientation was discovered after SF₆ gas insufflation of the anterior chamber and the orientation was then corrected intraoperatively.

Methods: A total of 371 consecutive DMEK cases using an S-stamp were analyzed and found to include 3 cases in which the DMEK graft was initially elevated with SF₆ gas in an upside down orientation, as demonstrated intraoperatively by the S-stamp. In each case, the graft was immediately manipulated into the proper orientation and the rescued case completed using our standard technique. The postoperative complications of these cases were reported and the percentage of endothelial cell loss at 6 months was compared with that of cases in this series without this rare intraoperative complication.

Results: All 3 rescued grafts achieved successful recipient corneal clearance and improved vision for the patient. There was no graft failure, rebubble, or rejection in these 3 cases. The average 6-month endothelial cell loss in the 3 initially inverted grafts was 51%, 58.3%, and 67% compared with 31.6% (SD ± 17.4%) in the series at large.

Conclusions: Incorporation of a stromal-sided S-stamp has been previously shown to reduce the risk of iatrogenic primary graft failure through the prevention of upside down graft implantation. In these 3 instances, although the stamp did not prevent initial upside down graft elevation, it did allow the surgeon to immediately recognize this rare problem, correct it intraoperatively, and prevent iatrogenic graft failure in each case.