We thank Drs Mittal and Senthil for their kind comments on our paper. Drs Mittal and Senthil highlighted the fact that certain subtypes of iridocorneal endothelial (ICE) syndrome are predisposed to worse graft-related outcomes. In our series, the rate of graft failure was higher in patients with essential iris atrophy than in patients with Chandler syndrome and Cogan Reese syndrome (46.7% vs 22.2%, P = .39). The difference did not reach statistical significance because of the small sample size in each subtype.
Drs Mittal and Senthil pointed out that glaucoma drainage device implantation may have been performed for eyes with more extensive peripheral anterior synechiae (PAS), and that this could be a reason for the higher graft failure rate. In our series, there were 5 eyes with extensive PAS (3 quadrants or more of anterior chamber angle closure on gonioscopy). Of these, 2 eyes underwent pre-keratoplasty glaucoma surgery. One eye underwent trabeculectomy while the other had glaucoma drainage device implantation, and both eyes underwent penetrating keratoplasty. The eye with glaucoma drainage device subsequently had graft failure due to graft rejection. We are unable to make any meaningful conclusion from this single event. Interestingly the intraocular pressure was controlled in these cases and hence was unlikely to contribute to the graft failure.
Lastly, Drs Mittal and Senthil asked if intraoperative cell loss would be greater in Descemet stripping automated endothelial keratoplasty (DSAEK) in ICE syndrome. Although we do not have complete data on postoperative endothelial cell counts, the graft survival rates at 1 year and 3 years were 100% and 80% for DSAEK and 93.8% and 75% for PK (both P = 1.00). This is in keeping with our results of DSAEK in pseudophakic bullous keratopathy cases but worse than Fuchs endothelial dystrophy. We agree that the surgery is more technically difficult in DSAEK owing to a disorganized anterior chamber, but with an appropriate inserter device similar graft survival rates to uncomplicated pseudophakic bullous keratopathy cases are achievable.