We congratulate Balachandran and associates on their excellent article regarding spontaneous corneal clearance despite graft detachment after Descemet membrane endothelial keratoplasty. They raise interesting questions and the possibility that Fuchs dystrophy may be treatable by either just stripping off the central Descemet membrane (DM) alone or by combining that with the mere insertion of a scrolled-up donor graft of DM and endothelium into the anterior chamber without subsequent positioning. They report low but gradually increasing cell counts in the recipient between 3 and 6 to 9 months. It has now been a year and a half since those surgeries. Have the central cell counts continued to improve with improving morphologic features, or have they stabilized? Would the authors consider joining or forming a multicenter study to evaluate this phenomenon?

In the second case, the donor endothelium clearly was implanted toward, or against, the recipient stroma and not toward the anterior chamber. Figure 2, Bottom right, and Figure 3 both show DM curled toward the anterior chamber; because the membrane curls with endothelium outward, the donor endothelium is facing the recipient stroma. In our experience, these grafts do not remain attached when oriented in that way.

Regarding the mechanism of corneal clearing, Koizumi and associates found in a monkey model that after removing DM, 4 of 4 treated corneas cleared after implanting a sheet with cultivated donor corneal endothelial cells, although the sheets detached within a week of implantation. In contrast, corneas in control eyes did not clear when a bare sheet was implanted or when a suspension of cultivated corneal endothelial cells merely was injected into the anterior chamber. In those experiments, the scraped area measured at least 9 mm in diameter and the corneal diameter was approximately 10 mm, so insufficient recipient corneal endothelial cells may have remained to repopulate the cornea.

Once again, congratulations on the development of yet another potential way to treat Fuchs dystrophy.