Purpose: To present 4 cases of postoperative repositioning of inverted grafts after Descemet membrane endothelial keratoplasty (DMEK).

Methods: Retrospective case reports of 4 patients presenting with subtotal to total graft detachment after DMEK, most probably owing to upside-down graft positioning. Graft repositioning was performed 1 to 14 days after initial DMEK surgery. In 3 cases (cases 1, 3, and 4), repositioning was performed without removing the graft from the anterior chamber (AC), whereas for case 2, the graft had to be removed from the AC to attain correct graft orientation.

Results: In all 4 cases, the initially upside-down DMEK grafts could be successfully repositioned postoperatively. Three cases showed complete graft attachment after graft repositioning with clear corneas until the last available follow-up. One case manifested a persistent central detachment with central corneal edema, eventually requiring re-DMEK. Endothelial cell density decreased from 2800 cells/mm² preoperatively to 2373 cells/mm² at 2 years postoperatively for case 1 and from 2600 to 600 cells/mm² at 6 months postoperatively for case 2. Case 3 showed a clear cornea until the last available follow-up at 1 year postoperatively.

Conclusions: In cases of upside-down grafts after DMEK, attempting to reposition the graft, with or without removing the graft from the AC, may be a cost- and tissue-efficient alternative before converting to re-DMEK.