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Gabison EE, Gree E, Azar G, Cochereau I, Guindolet D. Double-Docking Technique for Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty: A Retrospective Consecutive Case Series Study of Advanced Keratoconus. Cornea 2023; 42:1052-1056. [PMID: 37155354 PMCID: PMC10306333 DOI: 10.1097/ico.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/25/2023] [Accepted: 03/06/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE The aim of this study was to report the clinical outcomes and prognosis of femtosecond laser (FSL)-assisted double-docking deep anterior lamellar keratoplasty (DD-DALK) for advanced keratoconus (AK). METHODS Records of consecutive patients with keratoconus who underwent FSL-assisted DALK (DD-DALK) were reviewed. RESULTS We analyzed 37 eyes from 37 patients who underwent DD-DALK. Sixty-eight percent of eyes had a successful big-bubble formation and 27% had a manual dissection to achieve the DALK deep dissection. Stromal scarring was associated with not achieving a big bubble. Intraoperative conversion to penetrating keratoplasty was conducted in 2 cases (5%). The best-corrected visual acuity improved from a median (± interquartile range) of 1.55 ±0.25 logMAR preoperatively to 0.2 ±0.2 logMAR ( P < 0.0001). The median postoperative spherical equivalent was -5.75 ±2.75 D with a median astigmatism of -3.5 ±1.3 D. BCVA, SE, and astigmatism were not statistically different between patients who underwent DD-DALK and patients who underwent manual DALK. Stromal scarring was associated with big-bubble (BB) formation failure ( P = 0.003). All patients with failed BB requiring manual dissection had anterior stromal scarring. CONCLUSIONS DD-DALK is safe and reproducible. The success rate of BB formation is hampered by stromal scarring.
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Affiliation(s)
- Eric E. Gabison
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
| | - Eva Gree
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
| | - Georges Azar
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
| | - Isabelle Cochereau
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
- Ophthalmology Department, Bichat Claude-Bernard Hospital, Paris, France; and
- Université de Paris, Paris, France
| | - Damien Guindolet
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
- Ophthalmology Department, Bichat Claude-Bernard Hospital, Paris, France; and
- Université de Paris, Paris, France
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Lin C, Lee WS. Intraoperative optical coherence tomography-guided deep anterior lamellar keratoplasty. Taiwan J Ophthalmol 2023; 13:106-109. [DOI: 10.4103/tjo.tjo-d-22-00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/19/2022] [Indexed: 02/22/2023] Open
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Yu AC, Spena R, Pellegrini M, Bovone C, Busin M. Deep Anterior Lamellar Keratoplasty: Current Status and Future Directions. Cornea 2022; 41:539-544. [PMID: 34759197 DOI: 10.1097/ico.0000000000002840] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Deep anterior lamellar keratoplasty (DALK) involves selective replacement of diseased corneal stroma while preserving normal healthy endothelium. Despite several well-recognized advantages, the uptake of DALK has remained sluggish with an adoption rate that has plateaued over the past decade. Misconceptions such as the rarity of complications of penetrating keratoplasty, lack of standardization of the DALK technique, and limited substantial benefit in visual and refractive outcomes are frequently cited as arguments against performing DALK. This brief review discusses the recent findings that refute these perceived barriers; describes contemporary techniques, tools, and modifications in the surgical approach; and evaluates the evidence regarding the clinical outcomes of DALK.
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Affiliation(s)
- Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Rossella Spena
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Marco Pellegrini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Cristina Bovone
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
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Santorum P, Yu AC, Bertelli E, Busin M. Microscope-Integrated Intraoperative Optical Coherence Tomography-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty. Cornea 2022; 41:125-129. [PMID: 34369392 DOI: 10.1097/ico.0000000000002826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the feasibility of microscope-integrated intraoperative optical coherence tomography (OCT) for real-time quantitative analysis of surgical planes in big-bubble deep anterior lamellar keratoplasty (DALK). METHODS In this interventional case series, intraoperative OCT-guided big-bubble DALK was performed in 16 consecutive eyes of 16 patients with keratoconus. Trephination depth was measured using the intraoperative OCT caliper tool. Aiming for a depth within 150 μm from the endothelial surface, the trephination groove was extended to a deeper plane using a 15-degree blade. Repeat OCT scans were taken to measure residual stromal thickness before insertion of the DALK probe from the bottom of the extended trephination. Caliper measurements, success rate of pneumatic dissection, and complications were recorded. RESULTS After trephination, residual stromal thickness exceeded 150 μm in all eyes and averaged 257.1 ± 42.5 μm. In each case, the initial trephination groove was extended to a depth within 150 μm from the endothelial surface (118.9 ± 27.1 μm). Big-bubble formation was achieved in 12 eyes (75%). Type 1 bubble was obtained in 11 eyes. Perforation requiring conversion to penetrating keratoplasty occurred in 4 eyes during insertion of the cannula into a residual stromal bed of <100 μm (n = 2; 63 and 75 μm) or layer-by-layer dissection (n = 2). CONCLUSIONS Quantitative analysis of intraoperative OCT scans can be used to assist decision-making on whether to proceed with pneumatic dissection or extend the trephination groove, thereby facilitating insertion of the injection cannula at the desired stromal depth.
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Affiliation(s)
- Paolo Santorum
- Department of Ophthalmology, San Maurizio Regional Hospital, Bolzano, Italy
| | - Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Enrico Bertelli
- Department of Ophthalmology, San Maurizio Regional Hospital, Bolzano, Italy
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
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Preliminary Results of a Novel Standardized Technique of Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty for Keratoconus. J Ophthalmol 2020; 2020:5496162. [PMID: 32963820 PMCID: PMC7491466 DOI: 10.1155/2020/5496162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/06/2020] [Accepted: 08/25/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the feasibility and the initial outcomes of a novel standardized surgical technique of femtosecond laser- (FSL-) assisted big-bubble deep anterior lamellar keratoplasty (BBDALK) for eyes with keratoconus. Methods This prospective interventional case series included 11 consecutive FSL-assisted BBDALK procedures performed for the eyes with keratoconus from September 2019 to December 2019. The FSL was used to create (i) an intrastromal channel incision (1.7 mm in length, 4.6 mm in width, 80% depth, and cut energy of 1.70 μJ) and (ii) a 9.0 mm diameter circular lamellar side cut 65 μm above the endothelium (cut energy of 0.90 μJ) intersecting the intrastromal incision. In the operating room, a blunt dissector was used to open the intrastromal channel incision, through which a blunt spatula was inserted, tangentially advanced towards the center of the cornea, and replaced with a blunt cannula for pneumatic dissection. The subsequent surgical steps did not differ from the conventional technique. Main outcome measures were the success rate of pneumatic dissection and the percentage of intraoperative complications. Results Eleven eyes of 11 patients (6 males and 5 females; mean age: 34.54 ± 13.23 years) underwent FSL-assisted DALK. Using the FSL, both corneal incisions (lamellar side cut and intrastromal channel incision) were successfully created in all cases without the need for repeat docking or additional dissection. Pneumatic dissection with type 1 bubble formation succeeded in all 11 eyes (100%). DALK surgery was completed uneventfully in all cases. Descemet membrane perforation did not occur in any case, and no procedure was converted to penetrating keratoplasty. Conclusion Using standardized FSL parameters for both incision design and cut energy in BBDALK surgery, pneumatic dissection can be achieved in a very high rate of cases with minimal risk of intraoperative complications.
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Feizi S, Azari AA. Approaches toward enhancing survival probability following deep anterior lamellar keratoplasty. Ther Adv Ophthalmol 2020; 12:2515841420913014. [PMID: 32232195 PMCID: PMC7092383 DOI: 10.1177/2515841420913014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 02/07/2020] [Indexed: 12/16/2022] Open
Abstract
The greatest advantage of deep anterior lamellar keratoplasty over full-thickness corneal transplantation is the elimination of graft failure caused by endothelial rejection. Despite this advantage, a deep anterior lamellar keratoplasty graft can fail because of several factors, such as complications related to the donor-recipient interface, graft epithelial abnormalities, graft vascularization, stromal graft rejection, and recurrence of herpetic keratitis. Increased deep anterior lamellar keratoplasty graft survival is mainly built upon optimization of the ocular surface to provide a hospitable environment for the graft. Any predisposing factors for graft epithelial abnormalities, corneal neovascularization, and preexisting vernal keratoconjunctivitis should be identified and treated preoperatively. Prompt recognition and appropriate treatment of interface-related complications and stromal graft rejection usually result in good anatomic outcomes, with no detrimental effects on vision.
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Affiliation(s)
- Sepehr Feizi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Labbafinejad Medical Center, 9th Boostan St., Pasdaran Ave., Tehran 16666, Iran
| | - Amir A Azari
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Surgical Corneal Anatomy in Deep Anterior Lamellar Keratoplasty: Suggestion of New Acronyms. Cornea 2019; 38:515-522. [DOI: 10.1097/ico.0000000000001845] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Guindolet D, Nguyen DT, Bergin C, Doan S, Cochereau I, Gabison EE. Double-Docking Technique for Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty. Cornea 2018; 37:123-126. [PMID: 29095752 DOI: 10.1097/ico.0000000000001442] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a new and safe surgical technique of deep anterior lamellar keratoplasty (DALK) using the femtosecond laser (FSL) and intraoperative optical coherence tomography (iOCT) for surgical management of corneal thinning and/or opacities. The technique was coined the double-docking procedure for DALK (DD-DALK). METHODS FSL-integrated iOCT was used for direct visualization and calibration to perform precise anterior lamellar and side cuts for the removal of the anterior stroma. Air was then injected in the residual posterior stroma to detach Descemet membrane [big-bubble (BB) formation]. Returning the residual posterior stroma into the docked position, a cylindrical vertical cut was made with the FSL to securely open the BB roof. Next, the stromal roof of the BB was removed with forceps leaving Descemet membrane intact, followed by a lamellar corneal graft. RESULTS Anterior stroma resection, BB formation, and residual stromal resection were achieved in every case without perforation. The curved applanation surface helped to limit the formation of folds on the posterior stroma (ie, advanced thinning). CONCLUSIONS DD-DALK is a reproducible and safe procedure for surgical management of corneal thinning and/or opacities. The precision of stromal cuts made by the FSL and iOCT guidance for air injection increases success in DD-DALK preparation.
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Affiliation(s)
- Damien Guindolet
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France
| | - Diem T Nguyen
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France
| | | | - Serge Doan
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France
| | - Isabelle Cochereau
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France.,Université Paris Diderot, Sorbonne Paris Cite[Combining Acute Accent], France
| | - Eric E Gabison
- Cornea and External Disorders, Refractive Surgery Department, Fondation A. de Rothschild, Paris, France.,Hôpital Bichat Claude Bernard, Paris, France.,Université Paris Diderot, Sorbonne Paris Cite[Combining Acute Accent], France
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Feizi S, Javadi MA, Fekri Y. Use of deep anterior lamellar keratoplasty (DALK) for keratoconus: indications, techniques and outcomes. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1080/17469899.2016.1222904] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Big-bubble deep anterior lamellar keratoplasty using central vs peripheral air injection: a clinical trial. Eur J Ophthalmol 2016; 26:297-302. [PMID: 26541103 DOI: 10.5301/ejo.5000702] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare 2 sites of air injection to achieve Descemet membrane (DM) detachment in big-bubble deep anterior lamellar keratoplasty (DALK). METHODS In this prospective, randomized study, 48 eyes of 48 keratoconus-affected patients who underwent DALK by cornea fellows were enrolled. Each patient was randomly assigned into one of 2 groups. After trephination to approximately 80% of the corneal thickness, a 27-G needle was inserted into the stroma from the trephination site. The needle was moved radially inside the trephination site and advanced to the central or paracentral cornea in group 1. In group 2, the needle was inserted into the deep stroma from the trephination site and advanced into the peripheral cornea to approximately 1.5 mm anterior to the limbus. Air was gently injected into the deep stroma until a big bubble was formed. The rates of DM separation and complications were compared between the 2 groups. RESULTS Big-bubble formation was successful in 79.2% of the eyes in the study group. A bare DM was achieved by central injection in 68.0% of group 1 and by peripheral injection in 69.6% of group 2 (p = 0.68). This rate was increased to 80.0% and 78.3% in groups 1 and 2, respectively, after the injection site was shifted when injections failed. The study groups were comparable in terms of complications including DM perforation and bubble bursting. CONCLUSIONS Both injection sites were equivalent in their rates of big-bubble formation and complications. Less experienced surgeons are advised to initially inject air outside the trephination.
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Outcomes of Air Injection Within 2 mm Inside a Deep Trephination for Deep Anterior Lamellar Keratoplasty in Eyes With Keratoconus. Am J Ophthalmol 2016; 164:6-13. [PMID: 26772875 DOI: 10.1016/j.ajo.2015.12.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/30/2015] [Accepted: 12/31/2015] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate the outcomes of a new technique for deep anterior lamellar keratoplasty (DALK) employing the injection of air up to 2 mm inside a deep trephination (intended within 100 μm from the endothelial surface) obtained with a guarded trephine set by means of anterior segment optical coherence tomography (AS OCT). DESIGN Retrospective, noncomparative, interventional case series. METHODS The success rate and learning curve of pneumatic dissection in one clinical practice were analyzed in nonscarred keratoconic eyes undergoing a standardized DALK including 9-mm trephination intended to a depth within 100 μm from the endothelial surface, based on the thinnest AS OCT measurement at this site; and injection of air through a cannula advanced 1-2 mm centripetally from the bottom of the trephination. Surgical parameters, success rate of pneumatic dissection, and complications were recorded. RESULTS Eighty-eight eyes of 88 patients were included in the study. Pneumatic dissection succeeded in 75 of 88 eyes (85%). No significant correlation could be found between number of cases performed and success rate for this surgeon. Complications included loss of suction during trephination (n = 2, 2.3%) and perforation (n = 4, 4.6%). Conversion to penetrating keratoplasty was necessary in 1 case (1.1%). CONCLUSION Setting an adjustable trephine to a depth within 100 μm from the endothelial surface eliminates the need for reaching the central cornea for successful pneumatic dissection and substantially flattens the learning curve of DALK, while achieving a constant success rate above 80% and minimizing complications.
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Arnalich-Montiel F, Alió Del Barrio JL, Alió JL. Corneal surgery in keratoconus: which type, which technique, which outcomes? EYE AND VISION 2016; 3:2. [PMID: 26783544 PMCID: PMC4716637 DOI: 10.1186/s40662-016-0033-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/09/2016] [Indexed: 12/13/2022]
Abstract
Keratoconus is a disease characterized by progressive thinning, bulging, and distortion of the cornea. Advanced cases usually present with loss of vision due to high irregular astigmatism. A majority of these cases require surgical intervention. This review provides an update on the current treatment modalities of corneal surgery available for the management of advanced corneal ectasias.
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Affiliation(s)
- Francisco Arnalich-Montiel
- IRYCIS. Ophthalmology Department, Ramón y Cajal University Hospital, Madrid, Spain ; Cornea Unit, Hospital Vissum Madrid, Madrid, Spain
| | - Jorge L Alió Del Barrio
- Cornea and External Diseases Service, Moorfields Eye Hospital, London, UK ; Cornea, Cataract and Refractive Surgery Unit, Vissum Corporación, Alicante, Spain
| | - Jorge L Alió
- Cornea, Cataract and Refractive Surgery Unit, Vissum Corporación, Alicante, Spain ; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
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Pachymetry-guided intrastromal air injection ("pachy-bubble") for deep anterior lamellar keratoplasty: results of the first 110 cases. Cornea 2015; 34:625-31. [PMID: 25782400 DOI: 10.1097/ico.0000000000000413] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report intraoperative and 1-year postoperative results of the pachy-bubble technique for deep anterior lamellar keratoplasty (DALK). METHODS This prospective interventional case series included 110 eyes of 107 patients with anterior corneal pathology who underwent DALK, including 78 with keratoconus. Outcome measures included the rate of bubble formation, rate of completing DALK, bubble types, complications, and visual and keratometric parameters. RESULTS Intrastromal air injection was attempted in 109 eyes, and the air bubble was achieved in 93 eyes (85.3%). Intrastromal 2% methylcellulose injection was attempted in 9 eyes, after unsuccessful air bubble formation, and the viscobubble was achieved in 7 eyes (77.8%). Manual layer-by-layer dissection was performed in 8 eyes. Bubble formation was reached in 100 eyes (90.9%). Overall, 105 eyes (95.5%) achieved DALK. Air bubble occurred as type 1 (white margin) in 96.6% of the cases and as type 2 (clear margin) in 3.4%. There was a statistically significant improvement in all visual and keratometric parameters analyzed. Macroperforations converted to penetrating keratoplasty occurred in 5 eyes (4.5%) and microperforations in 12 (10.9%). There were significantly higher rates of perforation when a bubble was not achieved (P = 0.018) and when it was achieved as type 2 (P = 0.033). Interface haze occurred in 5 eyes (4.5%) and stromal rejection in 11 (10.0%). A short learning curve was observed for air bubble formation. CONCLUSIONS Bubble formation, especially type 1, is the key to decrease the risk of perforation in DALK. The pachy-bubble was safe, effective, and reproducible in promoting DALK with air bubble and viscobubble formation with a short learning curve.
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Feizi S, Javadi MA, Daryabari SH. Factors influencing big-bubble formation during deep anterior lamellar keratoplasty in keratoconus. Br J Ophthalmol 2015; 100:622-5. [PMID: 26311063 DOI: 10.1136/bjophthalmol-2015-307111] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate recipient and operative factors that can influence the rate of achieving a bare Descemet's membrane (DM) during deep anterior lamellar keratoplasty (DALK) for keratoconus. MATERIALS In this retrospective comparative study, a total of 290 (153 right) consecutive eyes from 257 (179 male) keratoconus-affected patients who underwent DALK with the big-bubble technique were enrolled. Univariate analyses and multiple logistic regressions were used to investigate factors including patient age and sex, family history of keratoconus, history of contact lens wear or vernal keratoconjunctivitis, the presence of Vogt's striae or superficial stromal opacities, keratometric readings, corneal diameter, central and peripheral corneal thickness, anterior chamber depth, vitreous length, and trephination size, which could predict achievement of a bare DM. RESULTS The surgery was completed as a DALK in 289 of 290 eyes, and a bare DM was successfully achieved in 229 (79.2%) eyes. The recipient sex and trephination size significantly influenced the success rate of big-bubble formation. Females had decreased odds of achieving a bare DM by 0.44 times (p=0.02). For each 0.1 mm increase in the trephination size, the odds of a successful big-bubble formation increased by 1.36 times (p=0.03). Other investigated factors did not significantly influence the rate of achieving a bare DM. CONCLUSIONS The rate of successful big-bubble formation was 79.2% in keratoconus. Among the different factors, recipient sex and trephination size significantly influenced this rate. Females had a lower probability of big-bubble formation, and a large trephination size was associated with an increase in the probability of achieving a bare DM.
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Affiliation(s)
- Sepehr Feizi
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed-Hashem Daryabari
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Response to "Pachymetry-Guided Intrastromal Air Injection ("Pachy-Bubble") for Deep Anterior Lamellar Keratoplasty: Results of the First 110 Cases". Cornea 2015; 34:e32. [PMID: 26266439 DOI: 10.1097/ico.0000000000000582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Knutsson KA, Rama P, Paganoni G. Modified big-bubble technique compared to manual dissection deep anterior lamellar keratoplasty in the treatment of keratoconus. Acta Ophthalmol 2015; 93:431-438. [PMID: 25764224 DOI: 10.1111/aos.12705] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/20/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the clinical findings and results of manual dissection deep anterior lamellar keratoplasty (DALK) compared to a modified big-bubble DALK technique in eyes affected by keratoconus. METHODS Sixty eyes of 60 patients with keratoconus were treated with one of the two surgical techniques manual DALK (n = 30); big-bubble DALK (n = 30). The main outcomes measured were visual acuity, corneal topographic parameters, thickness of residual stroma and endothelial cell density (ECD). Patients were examined postoperatively at 1 month, 6 months, 1 year and 1 month after suture removal. RESULTS Final best spectacle-corrected visual acuity (BSCVA) measured 1 month after suture removal was 0.11 ± 0.08 LogMAR in the big-bubble group compared to 0.13 ± 0.08 in the manual DALK group (p = 0.227). In patients treated with the big-bubble technique without complications (Descemet's membrane completely bared), the stromal residue was not measureable. Mean stromal residual thickness in the manual DALK group was 30.50 ± 27.60 μm. Data analysis of the manual DALK group demonstrated a significant correlation between BSCVA and residual stromal thickness; lower residual stromal thickness correlated with better BSCVA values (Spearman ρ = 0.509, p = 0.018). Postoperative ECD was similar in both groups at all intervals, with no statistically significant differences. In both groups, ECD loss was only significant during the 1- to 6-month interval (p = 0.001 and p < 0.001 in the big-bubble DALK and manual DALK groups, respectively). CONCLUSION Manual DALK provides comparable results to big-bubble DALK. Big-bubble DALK permits faster visual recovery and is a surgical technique, which can be easily converted to manual DALK in cases of unsuccessful 'big-bubble' formation.
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Affiliation(s)
| | - Paolo Rama
- Cornea and Ocular Surface Unit; San Raffaele Scientific Institute; Milan Italy
| | - Giorgio Paganoni
- Cornea and Ocular Surface Unit; San Raffaele Scientific Institute; Milan Italy
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Parker JS, van Dijk K, Melles GRJ. Treatment options for advanced keratoconus: A review. Surv Ophthalmol 2015; 60:459-80. [PMID: 26077628 DOI: 10.1016/j.survophthal.2015.02.004] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
Abstract
Traditionally, the mainstay of treatment for advanced keratoconus (KC) has been either penetrating or deep anterior lamellar keratoplasty (PK or DALK, respectively). The success of both operations, however, has been somewhat tempered by potential difficulties and complications, both intraoperatively and postoperatively. These include suture and wound-healing problems, progression of disease in the recipient rim, allograft reaction, and persistent irregular astigmatism. Taken together, these have been the inspiration for an ongoing search for less troublesome therapeutic alternatives. These include ultraviolet crosslinking and intracorneal ring segments, both of which were originally constrained in their indication exclusively to eyes with mild to moderate disease. More recently, Bowman layer transplantation has been introduced for reversing corneal ectasia in eyes with advanced KC, re-enabling comfortable contact lens wear and permitting PK and DALK to be postponed or avoided entirely. We offer a summary of the current and emerging treatment options for advanced KC, aiming to provide the corneal specialist useful information in selecting the optimal therapy for individual patients.
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Affiliation(s)
- Jack S Parker
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands; UAB Callahan Eye Hospital, Birmingham, Alabama, USA
| | - Korine van Dijk
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands
| | - Gerrit R J Melles
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands; Amnitrans EyeBank, Rotterdam, The Netherlands.
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Ghanem RC. Pachy-bubble and diamond knife-assisted deep anterior lamellar keratoplasty. J Cataract Refract Surg 2014; 40:1398. [PMID: 25088652 DOI: 10.1016/j.jcrs.2014.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Indexed: 11/27/2022]
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de Lima MHC, Rizzi AR, Simoceli RA, Cresta FB, Alves MR. Deep anterior lamellar keratoplasty with a manual spatula: anatomical and functional results. Indian J Ophthalmol 2014; 62:545-8. [PMID: 24881598 PMCID: PMC4065502 DOI: 10.4103/0301-4738.133483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: Evaluate the anatomical, refractive, and functional results of an innovative technique of deep anterior lamellar keratoplasty with a manual spatula. Materials and Methods: We evaluated the results and examinations of 16 eyes from 14 patients who underwent deep anterior lamellar keratoplasty using the technique described by Ferrara. Residual bed thickness after keratoplasty was evaluated postoperatively using Visante. The measurement was performed using a technique similar to that used to measure flap thickness after laser in situ keratomileusis refractive surgery. The measurements were performed at the center of the cornea in an area comprising the central 3-mm in the 45° and 135° meridians. Results: Best-corrected visual acuity was 0.34 ± 0.18 LogMar (0.09 to 0.60 LogMar), the spherical equivalent was -4.31 ± 3.38 D (+0.25 to -9.50 diopters), and keratometry was 45.75 ± 2.77 D (41.11 to 52.48 diopters) postoperatively. Corneal astigmatism was 3.19 ± 2.78 D (0.18 to 11.81 diopters). Residual stromal bed thickness measured by optical coherence tomography showed values of 67.1 ± 24.3 μm (30 to 109 μm). The statistical correlation by Spearman's test between the best-corrected visual acuity and the residual stromal bed thickness was 0.11 (P = 0.67). Conclusion: Deep anterior lamellar keratoplasty, in which manual dissection was performed using an instrument similar to that used to implant corneal rings, provided good visual and anatomical results.
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Affiliation(s)
- Mário Henrique Camargos de Lima
- Division of Cornea and External Disease, Clinics Hospital, University of São Paulo, HCFMUSP-SP, Division of Refractive Surgery of UNICO SP, Brazil
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Vajpayee RB, Maharana PK, Sharma N, Agarwal T, Jhanji V. Diamond knife–assisted deep anterior lamellar keratoplasty to manage keratoconus. J Cataract Refract Surg 2014; 40:276-82. [DOI: 10.1016/j.jcrs.2013.07.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 07/20/2013] [Accepted: 07/24/2013] [Indexed: 11/29/2022]
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Chew ACY, Mehta JS, Tan DTH. One Year of Cornea Research in Review-2012. Asia Pac J Ophthalmol (Phila) 2013; 2:401-13. [PMID: 26107152 DOI: 10.1097/apo.0000000000000022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The purpose of this study was to provide an update of significant cornea literature published in the past 1 year. DESIGN This was a literature review. METHODS The authors conducted a 1-year English-language literature search on PubMed, from January 1, 2012, to December 31, 2012, using the following terms: corneal transplantation, anterior lamellar keratoplasty, penetrating keratoplasty, endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty, Descemet membrane endothelial keratoplasty, Descemet membrane endothelial transfer, ocular surface epithelial transplantation, limbal epithelial transplantation, cultivated oral mucosal epithelial transplantation, keratoprosthesis, infectious keratitis, cross-linking, keratoconus, corneal neovascularization, corneal imaging, optical coherence tomography, Pentacam Scheimpflug imaging, and in vivo confocal microscopy. RESULTS This review includes original articles and review articles that contain significant updates and novel aspects in the field of cornea from the following journals: American Journal of Ophthalmology, British Journal of Ophthalmology, Ophthalmology, Investigative Ophthalmology and Visual Science, and Cornea. Letters to the editor, unpublished work, manuscripts not in English, and abstracts were not included. CONCLUSIONS This review highlights significant literature that is applicable to the practicing ophthalmologist.
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Affiliation(s)
- Annabel C Y Chew
- From the *Singapore National Eye Centre, †Singapore Eye Research Institute, ‡Duke-NUS Graduate Medical School, and §Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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da Silva Ricardo JR, Medhi J, Pineda R. Indications for and outcomes of deep anterior lamellar keratoplasty in mucopolysaccharidoses. J Pediatr Ophthalmol Strabismus 2013; 50:376-81. [PMID: 24669375 DOI: 10.3928/01913913-20131125-05] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe the outcome of deep anterior lamellar keratoplasty (DALK) for visually significant corneal clouding in patients with mucopolysaccharidoses (MPS). METHODS A retrospective consecutive case series of patients with MPS and corneal clouding were analyzed at a tertiary eye hospital. A review of the English literature regarding MPS and DALK was performed. The main outcomes measures of the study were intraoperative surgical complications, change in visual acuity, and postoperative DALK-related complications. RESULTS Four eyes from 2 patients with MPS I (Hurler's syndrome and Hurler-Scheie syndrome) and a history of DALK met inclusion criteria for the case series. Using the "big-bubble" technique, DALK was performed successfully in all eyes. Completed Descemet's membrane baring was achieved in 3 or 4 eyes and a pre-Descemet's membrane dissection in 1 eye. The mean age at the time of DALK was 17.3 years (range: 15.4 to 19.5 years). Mean follow-up time after DALK was 16.7 months (range: 6 to 31 months). Mean visual acuity before DALK was 20/80 (0.59 ± 0.12 logMAR). Mean visual acuity at the last visit for all 4 eyes was 20/50 (0.41 ± 0.17 logMAR). Visual acuity improved in all eyes. Recurrence of MPS corneal clouding was not noted in any of the corneal grafts. CONCLUSIONS DALK is a beneficial and preferable intervention in appropriate patients with significant corneal clouding due to MPS I. Improvement in vision can be obtained with stable, clear corneal grafts, although other ophthalmic manifestations may limit vision.
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