We appreciate the interest and comments on our recently published manuscript, “Clinical and Microbiological Profile of Post-Penetrating Keratoplasty Infectious Keratitis in Failed and Clear Grafts.” In this retrospective analysis, we found that patients with keratitis in failed grafts were older and had an early onset of graft infection as compared with patients with keratitis in clear grafts. Also, all patients in the failed-graft group were receiving long-term corticosteroid drop treatment at the time of presentation, compared with 76% of patients in the clear-graft group who were using corticosteroids.

We agree with Smith that although corticosteroids have been associated with the occurrence of infectious keratitis previously as well as in our study, the evidence for their implication in the current study would have been more convincing if there had been a control group of patients who used long-term corticosteroid eye drops but did not experience an infection. Future work is needed to understand the potential role of corticosteroid use in contributing to these infections. As mentioned in our manuscript, we are aware of the fact that low-dose topical corticosteroid use often is continued indefinitely after penetrating keratoplasty. However, we believe that this practice should be evaluated carefully in the face of the findings of our study. Furthermore, we wish to add that for achieving a stable and comfortable ocular surface in failed grafts, alternatives such as conjunctival grafts or amniotic membrane transplantation can be used in lieu of long-term corticosteroids.