Reply to Letter - Management of Upside-Down Descemet Membrane Endothelial Keratoplasty: A Case Series.

Dear Editor,

We thank Dr. Arjun Srirampur for his interest in our article “Management of upside-down Descemet membrane endothelial keratoplasty: A case series” .1

Regarding the timing of reorientation in case no. 1, there is no consensus from the current literature on the correct timing of intervention after the original procedure. This case and other reported cases in the literature show that there is a window of opportunity for the initial graft to resume full function with favorable outcomes. Mariacher et al. reported a similar case with longer follow-up where reorientation was done 4 weeks after the initial procedure with a favorable outcome.2 We believe 15 days between diagnosing an upside-down Descemet's membrane endothelial keratoplasty (DMEK) graft and reorientation is acceptable. Our patient needed this time to make special arrangements before his second procedure.

Regarding the type of tissue preservation used, all corneal tissues supplied by the National Health Service Blood and Transplant bank in Bristol, United Kingdom, are stored in organ culture medium “Dulbecco's Modified Eagle Medium” containing streptomycin, penicillin, and fetal calf serum.

We focused in this article on factors that are relevant to the upside-down grafts; this is why data on descemetorhexis and graft size relationship were not mentioned. The donor ages of original grafts were as follows: for the 5 cases, 74, 81, 81, 21, and 75 years in the order of mention in the original article. But again, we believe that this is not a relevant point to mention as we do not think it has a direct impact on the incidence of upside-down graft or an effect on the choice of management option or outcomes.

The use of an endoilluminator to judge DMEK graft orientation suggested by Jacob et al. is a good tool which we do not use routinely in initial DMEK procedures.3 It is a valuable tool when the anterior chamber view is limited because of corneal edema. We would like to add that it can also be helpful if used to assist reorientation of upside-down DMEK as the view is more limited compared to initial procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.