insertion techniques have embraced the NCI, and it has allowed them to do safe Descemet stripping automated endothelial keratoplasty (DSAEK) surgery. It is a welcome contribution to this field. Drs. Belin and Hannush have highlighted page 6 of our publication, 1 where we discuss the reasoning behind our decision not to use viscoelastic for the NCI-placed tissue, and they state that not using viscoelastic is atypical and not ‘‘standard practice.’’ The implication is that if we had used viscoelastic for the NCI tissue in this study, we would have had less cell loss for this randomized arm of the study. Standard practice with the NCI: The company that manufactures the NCI, Fischer Surgical (St. Louis, Missouri, USA) sponsored a breakfast meeting to talk about the product on October 20, 2010, during the meeting of the American Academy of Ophthalmology. At that meeting, which was moderated by Dr. Belin, a speaker, Dr. Anthony Lubniewski of Washington University (St. Louis, Missouri, USA), emphasized that one of the benefits of the NCI was that viscoelastic did not need to be used at all, so the cost savings resulting from omitting viscoelastic would offset the added expense of the device (confirmed by personal communication, August 26, 2013). In addition, the majority of surgeons using the NCI here on the West Coast also did not use viscoelastic at the time of our study. Therefore, not using viscoelastic would appear to be the preferred practice. However, just like Drs. Belin and Hannush, I do not have a scientific, broad-based survey of surgeons to produce the data that would demonstrate what is the ‘‘standard practice.’’ Endothelial protection with viscoelastic: Would a visco- elastic coating have improved our endothelial cell loss with the NCI? Not necessarily. The platform Endoserter device is very similar to the NCI and although Endoserter investi- gators 2 used viscoelastic, their endothelial cell loss was 28%. Similarly, the Endoglide insertion device uses visco- elastic, and the cell loss has been reported at 26%. 3 With the NCI’s internal fluid flow directly under the donor endo- thelium, any cohesive viscoelastic placed would likely be washed off during the extension of the platform for delivery of the tissue, eliminating any protective effect of the visco- elastic. Nonetheless, whether or not there is improved endothelial survival if viscoelastic is used to coat the donor tissue when using the NCI remains an unanswered question that calls for hard data. Until investigators perform a pro- spective, randomized, masked study of this question, the data from our highly controlled study stands. The NCI device and other insertion devices, for that matter, despite all of their other user benefits, have not been proven with prospective data to provide better endo- thelial cell survival than a well-established forceps inser- tion technique. Marketing the devices to the contrary contradicts the best available data. MARK A. TERRY Portland, Oregon REFERENCES 1. Terry MA, Straiko MD, Goshe J, Shamie N, Shah A, Alqudah AA, Davis-Boozer D. Endothelial keratoplasty: a pro- spective, randomized, masked clinical trial comparing an injector to forceps for tissue insertion. Am J Ophthalmol 2013;156(1):61–68. 2. Foster JB, Swan KR, Vasan RA, Greven MA, Walter KA. Small incision DSAEK: a comparison of a small incision tis- sue injector and forceps techniques. Cornea 2012;31(1): 42–47. 3. Gangwani V, Obi A, Hollick EJ. A prospective study comparing EndoGlide and Busin glide insertion techniques in Descemet stripping endothelial keratoplasty. Am J Ophthal- mol 2012;153(1):38–43. Incidence of Pineal Gland Cyst and Pineoblastoma in Children With Retinoblastoma During the Chemoreduction Era EDITOR: WE CAREFULLY READ THE RECENT PAPER BY RAMASUBRA- manian and associates on the incidence of pineal gland cyst and pineoblastoma in retinoblastoma patients. 1 Over a 12-year period this busy center saw only 4 pineo- blastomas in 408 patients. Despite the small numbers of pineoblastomas and admitted absence of statistical signif- icance, the authors concluded that ‘‘systemic chemother- apy.(may) possibly indicate a systemic protective effect.’’ As pointed out by the authors (and all prior publications on the subject), only the children with the genetic form of retinoblastoma are at risk for the development of pineo- blastomas, and all 4 of the patients in this series who devel- oped pineoblastomas had the genetic form. Yet when the authors calculated the incidence in the chemotherapy and no chemotherapy group they included unilateral patients (most) who are not at risk. They found 3 pineo- blastomas in 156 bilateral cases (only a few who may not have received systemic chemotherapy) and 1 pineoblas- toma in 252 patients who did not receive chemotherapy. However, the authors state that 215 patients in the series had germline disease and since 193 were bilateral that means that only 22 of the unilateral patients (most who probably did not receive chemotherapy) were at risk for second cancers (not the 215 listed in the manuscript). One patient in that group (1/22; 4.5%) developed a pine- oblastoma. Three of 198 bilateral patients (1.6%) devel- oped a pineoblastoma. (Our calculations indicate this difference is not significant.) The appropriate way to do the comparison would be to delete the unilaterals without germinal disease and compare those remaining patients who received chemo- therapy to those who did not (those data are not presented VOL. 156,NO. 6 1319 CORRESPONDENCE