We thank Chaurasia and associates for their thoughtful observations and questions regarding our article, “Spontaneous Reattachment of Descemet Stripping Automated Endothelial Keratoplasty Lenticles.” In response to their first comment noting that it would be useful to know the number of absolute lenticle dislocations, our study was an observational study, so absolute numbers of detachments were not collected as a denominator for statistical analysis, although this would have been a useful factor to examine.

The question was raised as to the rationale to observe patients rather than to rebubble immediately. In most cases, the graft was attached partially, so the decision was made to observe the patient, given that the lenticle was not free floating in the anterior chamber. However, there were some patients who were scheduled to undergo rebubbling the following week, but spontaneously reattached after performing activities like cleaning the floor in a face-down position for a prolonged period or for unknown reasons. Another patient could not undergo rebubbling because she had to return home to another state. When she returned for follow-up months later, spontaneous reattachment had occurred.

Chaurasia and associates also pose many interesting questions about the clinical appearance of our patients. Patients 2 and 3 had low postoperative vision because of poor visual potential from nerve pathologic features resulting from pre-existing glaucoma. Their grafts have remained clear and compact without any interface haze.

With regard to whether the reattached lenticles were displaced inferiorly, those patients who had peripheral attachment with only some central fluid were not displaced inferiorly. However, there were a couple patients who had inferior centration, perhaps because the lenticle was free floating in the anterior chamber.

Valid observations were made regarding the importance that postoperative intraocular pressure plays in the ability of Descemet stripping automated endothelial keratoplasty lenticles adhering to the cornea. Studies have reported that hypotony, whether it be from wound leak, the presence of filtering blebs, or glaucoma drainage devices, has resulted in a higher dislocation rate. In some cases, as was reported in our study, however, normalization of pressure and positioning may help some of these cases to demonstrate spontaneous reattachment.

Chaurasia and associates’ point about endothelial viability being retained during dislocation is well taken. As several studies have shown, rebubbling within a reasonable amount of time still can result in a clear and compact Descemet stripping automated endothelial keratoplasty lenticle. We found that likewise in these cases, spontaneous reattachments occur in the face of otherwise unremarkable Descemet stripping automated endothelial keratoplasty surgery and the lenticles still can clear. Although it would have been interesting to report endothelial cell counts, this was not the focus of the study. All cases clinically resulted in attached, clearing lenticles. For those cases for which we did have the cell counts (n = 4), on average, there were 1821 endothelial cells remaining (postoperative time range, 6 to 21 months).

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Jan 12, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Reply

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