Macrostriae in endothelial keratoplasty.

Sir,

We would like to congratulate Turaka et al., for their recently published article, Macrostriae and Descemet's membrane folds in the Descemet's stripping endothelial keratoplasty graft.[1] The authors describe a failed Descemet's stripping automated endothelial keratoplasty (DSAEK) with significant macrostriae requiring a repeat DSAEK. They provide excellent histopathological findings demonstrating the folds with associated endothelial atrophy.

We agree with the authors that having an edematous and thick graft may be a cause of persistent macrostriae. We have reported a similar case of graft folds in the visual axis which did not resolve over time.[2] However, our case did not lead to graft edema and failure, perhaps because it was a thinner graft. We have observed clinically that folds may occur in thinner grafts. As thin and ultra-thin DSAEK grafts are currently being studied to improve visual outcomes,[3] macrostriae may still be a complication. Thinner grafts are sometimes more difficult to manipulate surgically, and folds may occur intraoperatively. We thank the authors for sharing their findings. Whether macrostriae can only be attributed to thicker grafts is uncertain. We agree that more studies are needed to determine the etiology and improve management of this complication.