We describe a case of endothelial graft exchange in a patient who had inadequate vision without a clinically identifiable cause following Descemet-stripping endothelial keratoplasty (DSEK). The initial DSEK was performed with a hand-dissected donor, and the replacement graft was prepared with an automated microkeratome. The best spectacle-corrected visual acuity (BSCVA) improved from 20/50 before replacement to 20/25 after replacement. Although DSEK provides rapid recovery of excellent vision, few patients achieve a BSCVA of 20/20. Some have substandard vision with no clinically identifiable cause. This case demonstrates that replacing a hand-prepared graft with an automated microkeratome-prepared graft may improve vision in patients with no identifiable cause for visual loss.