An 87-year-old man with corneal edema due to Fuchs endothelial dystrophy underwent DSEK in his left eye. The graft detached postoperatively, necessitating repositioning 2 weeks after DSEK. At that time, the surgeon removed the corneal epithelium using a crescent blade to enhance visualization of the anterior chamber. In the postoperative period, the graft remained attached. However, the patient experienced a delay in corneal epithelial healing. The surgeon noted the presence of significant dry eye syndrome and placed a punctal plug in the lower tear duct. Subsequently, a bandage contact lens was placed to enhance epithelialization. Despite treatment with topical antibiotic agents, lubrication, and oral doxycycline, the patient's condition worsened. Six weeks after DSEK, the patient was referred to The Wilmer Eye Institute Ocular Surface Diseases and Dry Eye Clinic for further treatment. His visual acuity OS was counting fingers at 6 ft (180 cm). The cornea had significant edema and an area of 30% stromal thinning inferotemporally without an apparent infiltrate (Figure 1). The graft was attached, albeit slightly decentered. Corneal cultures were performed, and the patient was administered topical fortified antibiotics. Although the culture was positive for rare Propionibacterium acnes, the clinical findings did not improve with antibiotic drug therapy. Further thinning of the stroma occurred for several days. A detailed review of systems was positive for dry mouth, fatigue, and debilitating joint pains. Serologic testing revealed a significantly elevated C-reactive protein level but no autoantibodies. A right knee aspirate showed a small amount of white blood cells with no crystals. Based on the clinical findings, the patient was diagnosed as having seronegative rheumatoid arthritis and secondary SS. He was administered oral methotrexate and prednisone, as well as topical cyclosporine, 1%, and medroxyprogesterone acetate, 1%. One month later, his visual acuity was 2/200 OS with a failed graft, but there was complete resolution of the ulceration.