In Response.

Abstract

To the Editor: I have read with great interest the article by Sharma et al.1 on “Management of Post-DALK Recipient Posterior Stromal Scarring: A Novel Approach.” The authors have described a novel and cost effective approach to manage recipient posterior stromal scarring in postdeep anterior lamellar keratoplasty (DALK) patients that allows complete removal of the scarred recipient posterior stromal tissue. However, I would like to point out few concerns. First, it would be interesting to know whether there was any postoperative Descemet stripping endothelial keratoplasty (DSEK) graft detachment or not after the surgery in any of the 10 eyes. As the DSEK lenticule was attached to an irregular surface of the cut DALK under surface, the chances of improper attachment of the DSEK lenticule to the overlying DALK are high. This improper attachment could lead to early graft detachment. Nahum et al.2 have shown that previous keratoplasty graft itself is a high risk for postoperative DSEK graft detachment. Hence, it would be informative to know about this aspect in the article. Second, as there would be an interface between the DALK and DSEK graft, it can result in significant reflectivity of light and result in poor quality of vision. Transplantation of the posterior stroma leads to an increase in corneal thickness, the creation of host–donor interface that can influence postoperative visual performance.3 Hence, analyzing the postoperative aberrations can help to evaluate the quality of vision in these eyes. Also, the problems associated with the interface in lamellar keratoplasty like infections, epithelial ingrowth, interface debris etc have to be kept in mind when contemplating a DSEK instead of a full-thickness penetrating keratoplasty. Third, as there were two grafts from separate donors, the chances of graft rejection would be high.4 As these patients were followed up for only 3 months postoperatively, it would be important to have a longer follow-up to know the long-term prognosis and survival of these grafts. Whether, any perioperative steroids or immunosuppressants were given or not is not elucidated. Fourth, the primary indication for the DALK was not mentioned in the article. One of common reasons for a persistent scar after a DALK would be a recurrence or residual herpes simplex virus (HSV) scar. These eyes if operated and the underlying stroma being excised along with an additional transplant in the form of DSEK would lead to recurrence or reactivation of the HSV infection. In such eyes, it would be important to start prophylactic acyclovir both preoperatively and maintain postoperatively to prevent any recurrence. Finally, the time interval between the primary DALK and subsequent DSEK should have been mentioned. This is important as the residual astigmatism after all the suture removal would guide the surgeon in deciding whether to plan a Penetrating Kertaoplasty when the astigmatism is high versus DSEK when the residual astigmatism is low. To conclude, all these parameters would add more information to this novel and simple technique described by the authors to manage the recipient posterior stromal scarring in eyes that underwent DALK. Arjun Srirampur, M.S., F.R.C.S. Department of Cornea and Refractive Surgery, Anand Eye Institute, Hyderabad, India