We read with interest the article entitled “Spontaneous Reattachment of Descemet Stripping Automated Endothelial Keratoplasty Lenticles,” by Hayes and associates. The authors reviewed a significant number of spontaneously attached Descemet stripping automated endothelial keratoplasty (DSAEK) lenticles and provided information about natural course of graft detachment after DSAEK. We would like to offer some comments and observations.

The study includes a cohort of patients who demonstrated spontaneous reattachment of detached lenticles after DSAEK. It would be useful to know the denominators: the absolute number of graft detachments and the number and eventual outcome in the patients (if any) who did not demonstrate reattachment on conservative approach. Also, was the reason to observe rather than intervene in all these cases uniform?

The authors report that 10 patients had an attached and clear lenticule. Patients 2 and 3 gained visual acuity of 20/100 and 20/200, respectively. It has been noted by Tarnawaska and Wylegala that interface fluid for a prolonged period may be complicated by interface haze and fibrosis. Did the authors also note interface haze or scarring contributing to subnormal vision? It is logical to conclude that grafts that reattach spontaneously are likely to have an inferior decentration because of gravitational force in the upright position. We also have noted similar decentrations. What was the location of the spontaneously reattached lenticles?

The authors noted that 2 of the cases had abnormal intraocular pressure. We believe this may be of remarkable significance. Based on our own experience with 2 patients who underwent DSAEK and had a prior history of glaucoma filtering surgery, we are inclined to believe that it is the sudden or rapid lowering of the intraocular pressure in the early postoperative period that may be a predisposing factor for graft detachment. In 1 of our 2 cases, the patient who had a well-attached graft with less than half anterior chamber filled air bubble on the immediate postoperative day, a raised intraocular pressure of 42 mm Hg occurred on the fourth postoperative day. He was treated with oral acetazolamide 500 mg 3 times daily and timolol ophthalmic eye drops for 2 days. Subsequently, the patient demonstrated a complete graft detachment 2 days later (presumably because of sudden hypotony) that was attached successfully and remained clear after rebubbling. In the second case, the patient reported rubbing his eye vigorously on the fourth postoperative day. He sought treatment for a larger bleb, hypotony, shallowing of the anterior chamber, and a partially detached lenticle, which resolved spontaneously after maintenance of a supine posture for few hours and normalization of intraocular pressure.

Another important observation and conclusion derived indirectly from the study is that endothelial viability is retained even with prolonged duration of detachment. So, it is possible that rebubbling procedure still may be successful, even if it was delayed under any circumstances. Also, it would be very useful to obtain the data on endothelial cell counts in all spontaneously cleared grafts.