Eyes with a failed PK are usually complex, resulting from a variety of issues. Whenever possible, the corneal surgeon should understand the reasons behind a donor tissue failure. There is great incentive to take advantage of newer Descemet-stripping endothelial keratoplasty (DSEK) techniques that offer more rapid healing; better structural integrity, refractive stability, and predictability; reduced medications; and decreased infection risk over the long term. Unfortunately, not every patient with a failed PK can be reduced to endothelial dysfunction. Additional PK may be indicated to re-establish both optical and structural function.