We read with interest the article by Wu and associates, “Graft Rejection following Descemet Stripping Automated Endothelial Keratoplasty: Features, Risk Factors, and Outcomes.” There were a few gray areas in the article that require clarification.
The authors included only patients with 3 months of follow-up, making it a nonconsecutive case series. There are no definite guidelines regarding the timeline definition of graft rejection after Descemet stripping automated endothelial keratoplasty. Considering the definition of graft rejection after penetrating keratoplasty, which includes all grafts that technically have been successful and have remained clear for at least 2 weeks, we would like to know whether any patient had a rejection episode before the 3-month period. We would also like to know the clinical profile and fate of such patients.
Although there was no significant statistical correlation noted between the indication of Descemet stripping automated endothelial keratoplasty and rejection rates, it is important to note that 4 (14.29%) of 28 patients had a failed graft and subsequent graft rejection compared with 12 (8.75%) of 137 patients with Fuchs endothelial dystrophy. The percentage of patients with a failed graft who experienced rejection was almost double than that of those with Fuchs endothelial dystrophy, making indication for surgery a clinically significant risk factor for rejection.
Twenty-two of 30 patients recovered from the rejection episode. It would be interesting to learn the clinical profile of patients whose rejection episode did not resolve and progressed to graft failure. This would allow the clinicians to be vigilant while dealing with cases that have poor outcomes after rejection.
We would like to know what regimen of topical steroids the authors now follow for their patients who have undergone Descemet stripping automated endothelial keratoplasty with and without steroid response.