Comment on Descemet membrane endothelial keratoplasty without peripheral iridotomy: Outcomes and safety profile

Dear Editor, We thank the authors for conducting this important work to address a question central to partial thickness corneal transplantation. We congratulate them on their successful outcomes, robust analysis, and careful methodology—particularly commendable in an area with a paucity of literature. We agree optimizing visual outcomes while avoiding surgical iridotomy offers meaningful benefits, from reducing glare, monocular diplopia, and higher-order aberrations to minimizing unnecessary inflammation, fibrin formation, bleeding, and intraoperative difficulties that may impact graft unfolding and surgical success. In reviewing the authors’ results, we noted several factors of interest compared with our own practice patterns and those of partner colleagues. The protocol of reducing the gas fill at 1 hour postoperatively may have been critical to lowering pupillary block (PB) incidence; this step, and the degree of air release at the slit lamp, can vary between surgeons and may influence reproducibility. The use of C3F8 in select cases is another variable worth consideration. Our practice predominantly uses sterile air or, in certain cases, SF6 for its predictable expansion and rapid resorption, which may help mitigate delayed PB, as in one of the reported cases. We are also curious about the postoperative medication protocol, particularly the use of cycloplegics (e.g., atropine) and aqueous suppressants (e.g., brimonidine), which may influence PB and early IOP control.[1] We also note that PB incidence could be underestimated where tonometric POD1 IOP measurements were not performed in symptomatic patients, where gentle tactile palpation may have been of use to support ruling out PB.[2] Again, we commend the authors for a valuable contribution to a topic of immense interest and look forward to further collaborative efforts toward minimizing adverse events while optimizing visual rehabilitation. Sincerely, Authors Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.