Response to "YAG Laser Treatment for Epithelial Ingrowth in Descemet Membrane Endothelial Keratoplasty Interface".

To the Editor: We read with interest the case report by Jenkins et al1 entitled “YAG laser treatment for epithelial ingrowth in Descemet membrane endothelial keratoplasty interface.” The authors describe successful management of epithelial ingrowth with yttrium aluminum garnet (YAG) laser treatment with a follow-up of 4 months. The cause of ingrowth was unknown and could have derived from the donor during initial preparation (prestripped tissue) or from the host, with introduction of epithelial cells during surgery because the graft was in contact with the corneal wound. Ingrowth of the interface has been reported in both Descemet membrane endothelial keratoplasty and Descemet-stripping automated endothelial keratoplasty (DSAEK).2,3 In literature, management of these cases ranges from observation and treatment options such as intracameral 5fluorouracil, repeat DSAEK, or penetrating keratoplasty (PK).3,4 PK particularly allows complete removal of epithelial cells by leaving an unaffected margin and is most likely the safest technique in relation to the risk for scattering epithelial cells in the anterior chamber. In the largest reported cases series of ingrowth after DSAEK, 9 of 13 patients were observed over time with no significant variations. When epithelial cells are localized in the graft-host interface, in most cases, growth is not particularly aggressive and can be easily monitored. On the contrary, after potential scattering of epithelial cells in the anterior chamber, localization and monitoring of growth can be difficult. When surgical intervention is necessary, repeat DSAEK and PK have the advantage of providing excised tissue that can be used for histopathologic analysis, allowing confirmation of diagnosis. Even though confocal microscopy has shown a good correlation with histopathologic analysis,5 distinguishing epithelial cells in the interface might be challenging in some cases. Considering that the differential diagnosis of epithelial ingrowth in the interface is microbial interface keratitis, a correct diagnosis is fundamental.6 YAG laser treatment is a procedure that can potentially disseminate epithelial cells or microorganisms in the anterior chamber and should not be encouraged, especially with limited data represented by one case report with a very short follow-up of 4 months.