Letter to the Editor—Regarding “10-year outcome of Descemet stripping only in a patient with Fuchs endothelial dystrophy”

Dear Editor,

We read with interest the article by Moayed et al. entitled “10-Year Outcome of Descemet Stripping Only in a Patient with Fuchs Endothelial Dystrophy.” ¹ The authors are to be commended for reporting this unique case with the longest single-patient follow-up after Descemet Stripping Only (DSO), providing valuable insight into the very long-term evolution of this technique.

We agree that the evaluation of the long-term outcomes after DSO is imperative for establishing the validity of this procedure, this is why we reported the “Long-Term Follow-Up of Descemet Stripping Only: Data Up to 7 Years Postoperatively” (Rizk et al., Cornea, November 2023), ² which is unfortunately not referenced in this article. Our study involved 26 eyes of 20 patients making it to our knowledge the largest series with the longest follow-up period for DSO extending to 7 years.

Our cohort study complements the authors’ report in several important ways and adds valuable insight to your report.

First, it demonstrates that sustained improvements in best-corrected visual acuity (from 0.30 ± 0.17 to 0.09 ± 0.13 logMAR, p < 0.05) and central corneal thickness (from 588 ± 41 µm to 546 ± 50 µm, p < 0.05) are achievable and durable in a larger population.

Second, in our study, we systematically documented endothelial cell counts both centrally and peripherally. In fact, one of the inclusion criteria for performing DSO procedure was a peripheral cell count of >1000 cells/mm², to ensure good peripheral cell pool that could migrate post-operatively. We also monitored peripheral endothelial cell count (ECC), polymegathism, and polymorphism as potential prognostic factors. By contrast, in your case report, no peripheral ECC data were included.

The surgical technique also deserves consideration. In the presented case, a 360° scoring and peeling approach was used. In our experience, care must be taken to avoid stromal trauma, as subtle injury can compromise endothelial migration and contribute to failure. We advocate a small, central (≈4 mm) descemetorhexis performed by peeling alone, without any peripheral scoring, as this minimizes tissue damage and is proven to be associated with better outcomes.

It is possible that the 360° scoring technique contributed to the primary failure observed in the patient’s left eye. In addition, the absence of peripheral ECC measurement makes it difficult to assess whether there was sufficient endothelial reserve to ensure migration and repopulation—another potential factor underlying the left eye’s unsuccessful outcome.

Neither the patient in your study nor our cohort received postoperative Rho kinase inhibitors. The fact that both studies demonstrate successful corneal clearance and vision recovery over time underscores that DSO can provide long-term benefit in the absence of adjunctive ROCKi therapy, while ongoing trials may clarify their potential additive role.

In summary, we commend Moayed et al. for their 10-year case, but we believe our 7-year, largest-to-date series provides essential complementary evidence. Taken together, these findings support the relevance of DSO as a durable, graft-sparing option in carefully selected patients with FECD.