Sir,

We thank Mr B Ilango for his interest in this article.1 In response to his specific comments:

Marking the cornea before lamellar dissection or performing a partial trephination does allow the area of lamellar dissection to be reduced. However, extending the lamellar dissection well beyond the trephination margin allows Descemet's membrane to be pushed further back from the stroma with Healon™ reducing the risk of inadvertent full thickness penetration during trephination.

We agree that in order to achieve a good anterior contour to the cornea the suture bites in donor and recipient may need to be at different depths, with the suture exiting the donor at two-thirds thickness and entering the recipient within the lamellar pocket, that is, almost full thickness.

Graft resuturing was required for five patients in each group. Over tightening of the sutures was avoided in order to reduce the amount of early astigmatism but the cost may have been early suture loosening in these patients. Suture tightening is always a matter of judgment and although strain gauge forceps have been developed2 we are unaware of any good evidence to show that these have impacted on resuturing rates. In the subsequent 100 deep anterior lamellar keratoplasties we have performed since this paper was written, the rate of resuturing required has been less than 5%.

We wish Mr Ilango well with his prospective study of visual outcomes and dissection depth in deep anterior lamellar keratoplasty.