We read with interest the article titled “Graft failure and intraocular pressure control after keratoplasty in iridocorneal endothelial syndrome” by Quek and associates. The subject is of great interest and the authors have addressed the issues in a very methodical way. The authors concluded that the cumulative probability of graft survival in iridocorneal endothelial (ICE) syndrome patients was similar following penetrating keratoplasty (PK) or Descemet stripping automated endothelial keratoplasty (DSAEK) and that the presence of glaucoma drainage device, as compared to trabeculectomy, was associated with significantly higher risk for graft failure. We would like to know whether the outcomes were any different in specific variants of ICE syndrome. In our own patients, we see a poorer outcome in those with essential iris atrophy vs the other 2 variants, namely Chandler syndrome and Cogan Reese syndrome.

Usually glaucoma drainage device implantation is done for eyes with more severe forms of the disease with extensive peripheral anterior synechiae, where trabeculectomy may not have been possible. Could it be that the reason for higher failure rate is due to more advanced disease in these eyes? The advanced nature of the disease itself may also be a contributing factor to graft failure in these eyes.

Performing DSAEK is more difficult than PK in ICE syndrome because of the disorganized anterior chamber in these eyes. One would expect more endothelial cell loss intraoperatively in DSAEK. Do the authors have a data on endothelial changes in these patients?