Aims: The aim of this study is to characterise corneal epithelial thickness profiles after Descemet membrane endothelial keratoplasty (DMEK) and compare it with healthy controls, focusing on inferior–superior (I–S) epithelial thickness differences and their relationship with age. Methods: This single-centre observational study included 36 post-DMEK eyes with at least 6 months’ follow-up and 36 healthy control eyes. High-resolution spectral-domain anterior segment OCT maps were analysed for central epithelial thickness (CET, defined as the mean epithelial thickness within the central 2 mm zone [E2.0]) and peripheral sectors to derive inferior (E–I) and superior (E–S) values (between 2 and 7 mm), with the I–S difference computed at a 3 mm radius; group comparisons used t-tests and correlations used Pearson’s r (α = 0.05). Central corneal thickness (CCT) was also compared between groups. Results: Post-DMEK eyes had significantly lower mean CCT than controls (525.7 ± 98.4 μm vs. 544.71 ± 27.8 μm, p = 0.04). Central epithelial thickness did not differ between groups (post-DMEK 53.7 ± 5.5 μm vs. controls 52.7 ± 3.3 μm, p = 0.62), but the I–S epithelial difference was greater after DMEK (5.9 ± 4.3 μm) than controls (3.0 ± 2.2 μm, p < 0.01), indicating a more pronounced inferior thickening pattern. Age showed no significant relationship with epithelial thickness in controls, and only very weak or non-significant correlations with central thickness and I–S difference in post-DMEK eyes, indicating no clinically meaningful age effect postoperatively. Conclusions: DMEK restores central epithelial thickness to values comparable to normal eyes, while accentuating the physiologic inferior–superior epithelial gradient, consistent with localised postoperative epithelial remodelling rather than global epithelial thickening or thinning. Corneal stromal remodelling may result in lower CCT post-DMEK versus controls, and age does not meaningfully influence epithelial distribution after surgery.

Purpose: To analyse the outcomes of deep anterior lamellar keratoplasty (DALK) in cases with intraoperative Descemet membrane (DM) perforation. Methods: This is a literature review reporting outcomes of DALK with DM perforation. Studies where DALK was performed in the event of intraoperative DM perforation were included. Studies that did not separate analysis between those with and without DM perforation were excluded. The primary outcome was best‐corrected distance visual acuity (BCVA). Secondary outcomes were endothelial cell density (ECD), graft survival, rejection rates, double anterior chamber and conversion to penetrating keratoplasty (PK). Data from the included studies were collated to compare the outcomes of DALK with intraoperative DM perforation vs. DALK without DM perforation. Results: Eleven retrospective case series (357 eyes) were included. DM perforations were classified as micro‐ ( n = 236) or macroperforations ( n = 106). Mean weighted preoperative BCVA was 1.11 ± 0.36 logMAR and 1.13 ± 0.52 logMAR in perforation and nonperforation groups, respectively ( p = 0.53), improving to 0.35 ± 0.37 logMAR and 0.39 ± 0.07 logMAR at 12 months postoperatively ( p = 0.02). Graft rejection rates were 1.25% and 1.6% in the perforated and nonperforated groups, respectively, and primary graft failure rates were 4% and 3.74%, respectively. The mean postoperative ECD was 1662.41 ± 319.16 cells/mm ² in the perforation group. Amongst those cases with DM perforation, double anterior chamber requiring rebubbling occurred in 22.4% of cases, and conversion to PK was 4.23%. Conclusion: DALK can achieve comparable long‐term outcomes in the presence of DM perforation. Micro‐ and some macroperforations can often be managed without conversion to PK, with good long‐term outcomes.