Repositioning or removal of the GDD is often necessary and presents a surgical challenge. When the position of the tube in the anterior chamber compromises the cornea, it is often necessary to reposition the tube further posterior in the anterior chamber or even place it in the ciliary sulcus or pars plana to prevent further damage to the corneal endothelium. If done early enough, the need for additional surgical procedures to clear a decompensated cornea can potentially be avoided. However, in many cases, patients have an edematous cornea and a tube that is positioned poorly. In these cases, either a penetrating keratoplasty or endothelial keratoplasty needs to be performed for visual rehabilitation. Prior to or concurrent with the corneal surgery, it is often necessary to reposition the tube to avoid damage to the endothelium of the corneal graft. In patients undergoing penetrating keratoplasty and tube repositioning, it is imperative that the original fistula site be closed tightly so that the eye remains stable with an adequate pressure while the donor cornea is sutured in place. Leakage from the fistula site will result in difficulty maintaining the anterior chamber, leading to potential endothelial damage from repeated collapse of the chamber. One of the most critical steps during the endothelial keratoplasty procedure is the placement of an air bubble to support the donor lenticle and brief elevation of IOP to assist graft attachment. All wounds need to be watertight during this part of the procedure as air will escape from any potential site of leakage. Air leakage can result in partial or complete donor detachment. Hence, when tube repositioning is combined with either a penetrating keratoplasty or endothelial keratoplasty, adequate closure of the fistula site is critical to maximize the chances of an optimal outcome.