Descemet's stripping endothelial keratoplasty (DSEK) has revolutionised corneal transplantation in cases with pure endothelial dysfunction. Recently, DSEK has become a popular procedure among paediatric corneal surgeons globally for pure endothelial dysfunction, because it is said to provide early visual rehabilitation and an improved safety profile compared with traditional penetrating keratoplasty (PKP).1 ,2 Does it though?

In this issue, Ashar et al3 attempt to answer this question by describing a paired-eye comparison of DSEK and PKP in children with congenital hereditary endothelial dystrophy (CHED).

The authors have compared the outcomes of two techniques in the fellow eyes of the same patient at 1-year follow-up in terms of graft clarity, visual outcome and complications. There was no significant difference in the spherical component of the refraction with significantly lower astigmatism in DSEK. Although all the grafts were clear at 1 year, the authors observed that the graft clarity after DSEK never reached that obtained after PKP. Why should that be?

A review of all the series published thus far on endothelial keratoplasty in children is summarised in table 1. There are a total of 54 eyes of 45 patients who underwent …