1
|
Cho SY, Yoon JH, Koo MA, Whang WJ, Na KS, Kim EC, Kim HS, Hwang HS. Retrospective Analysis of a New Intrastromal Dissection Technique Using the Retinal Reflex for Deep Anterior Lamellar Keratoplasty. Cornea 2024; 43:1128-1136. [PMID: 38251908 PMCID: PMC11296286 DOI: 10.1097/ico.0000000000003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/06/2023] [Accepted: 10/30/2023] [Indexed: 01/23/2024]
Abstract
PURPOSE The purpose of this study was to describe a new surgical technique for deep anterior lamellar keratoplasty. METHODS All pupils in the recipient eyes were dilated preoperatively. Vertical grooving was performed using a crescent blade with a width of 5 mm and a depth of one-third to half corneal thickness on the temporal side of the limbus. Stromal dissection was performed as close as possible to Descemet membrane by observing the gap between the gold line by retinal reflex and the front edge of the crescent blade. Lamellar dissection was performed along the lamellar plane using corneal dissectors. The ophthalmic viscoelastic device was injected into the intrastromal pocket to separate the anterior and posterior stroma and an anterior corneal lamella was excised. A donor cornea was sutured into the recipient bed. RESULTS In 18 eyes, none of the patients had Descemet membrane rupture during surgery. The mean postoperative residual stromal thickness was 80 ± 31 μm. The mean central corneal thickness after surgery was 660 ± 69 μm. At the last follow-up, the cornea was cleared in all 18 eyes on slit-lamp examination. CONCLUSIONS We estimated the residual stromal thickness based on the gap between the gold line by the retinal reflex and crescent blade, and intrastromal lamellar dissection was performed using a smooth corneal dissector. Consequently, the surface of stromal dissection was smooth, and the residual stromal thickness was even.
Collapse
Affiliation(s)
- Soo Yeon Cho
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Hyun Yoon
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Minjeong A. Koo
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woong Joo Whang
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Sun Na
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Chul Kim
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Seung Kim
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Sik Hwang
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
2
|
Alfonso-Bartolozzi B, Fernández-Vega-Cueto L, Fernández-Vega L, Martínez-Alberquilla I, Madrid-Costa D, Alfonso JF. Triple Procedure: A Stepwise Combination of Deep Anterior Lamellar Keratoplasty and Cataract Surgery. Cornea 2024; 43:301-306. [PMID: 37603699 DOI: 10.1097/ico.0000000000003364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/05/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE The aim of this study was to evaluate clinical outcomes of the combined surgery (triple procedure) of deep anterior lamellar keratoplasty (DALK), phacoemulsification, and intraocular lens (IOL) implantation using a new surgical strategy. METHODS The study included 43 eyes of 43 patients who underwent a triple procedure. Twenty-six eyes with good visibility through the cornea underwent phacoemulsification before the stromal dissection. Seventeen eyes with bad visibility underwent the DALK procedure first until achieving enough visibility to perform the lensectomy. IOL power calculation was performed for a postoperative estimated flat keratometry of 43.5 and aiming to avoid hyperopic postoperative refraction. The postoperative visual examination included uncorrected and corrected distance visual acuity (CDVA) measurements and manifest refraction. RESULTS The mean follow-up time after suture removal was 3.06 ± 2.14 years. Mean CDVA significantly changed from 0.86 ± 0.56 logMAR preoperatively to 0.37 ± 0.28 logMAR in the last visit ( P < 0.0001). The percentage of eyes with CDVA ≤0.3 logMAR changed from 6.9% preoperatively to 62.8%. No eyes lost lines of vision after surgery, and 80% experienced an improvement of 2 or more lines. The safety index was 2.2. The mean postoperative refractive sphere was +0.13 ± 2.04 D, and the postoperative refractive cylinder was -4.02 ± 2.24 D. Only 2 cases (4.65%) obtained postoperative hyperopic astigmatism. No intraoperative complications were found. CONCLUSIONS Combined surgery of DALK, phacoemulsification, and IOL implantation is an effective and safe procedure. Depending on the corneal transparency, different surgical strategies can be established to provide more efficacy and safety.
Collapse
Affiliation(s)
| | | | | | - Irene Martínez-Alberquilla
- Clinical and Experimental Eye Research Group (CEER), Optometry and Vision Department, Faculty of Optics and Optometry, Universidad Complutense de Madrid, Madrid, Spain
| | - David Madrid-Costa
- Clinical and Experimental Eye Research Group (CEER), Optometry and Vision Department, Faculty of Optics and Optometry, Universidad Complutense de Madrid, Madrid, Spain
| | - José F Alfonso
- Fernández-Vega Ophthalmological Institute, Oviedo, Spain; and
| |
Collapse
|
3
|
Lucisano A, Scorcia V, Taloni A, Rossi C, Gioia R, Giannaccare G. Impact of topographic localization of corneal ectasia on the outcomes of deep anterior lamellar keratoplasty employing large (9 mm) versus conventional diameter (8 mm) grafts. Eye (Lond) 2023; 37:3477-3483. [PMID: 37081075 PMCID: PMC10630389 DOI: 10.1038/s41433-023-02536-6] [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: 01/05/2023] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES Visual and topographic outcomes of large (9.0 mm) versus conventional (8.0 mm) deep anterior lamellar keratoplasty (DALK) for the treatment of keratoconus (KC) were compared in relation to the different localization of the corneal ectasia (within or beyond the central 8.0 mm). METHODS This is a retrospective, comparative case series. Preoperatively, the topographic extension of the conus was calculated by measuring the distance from the geometric center of the cornea and the outermost point of the corneal ectasia (ectasia <8.0 mm, group A; ectasia ≥8.0 mm, group B). DALK was performed using both small grafts (8.0 mm, group 1) and large grafts (9.0 mm, group 2). Best-corrected visual acuity and topographic astigmatism were evaluated preoperatively (T0) and postoperatively after complete suture removal (1 year, T1). RESULTS Data from 224 eyes of 196 patients (mean age 37.6 ± 15.1 years) were evaluated. Topographic astigmatism improved from T0 to T1 (4.94 ± 2.92 diopters (D) [95% CI, 4.56-5.33] vs 4.19 ± 2.45 D [95% CI, 3.87-4.51], p = 0.001). There was no significant difference in postoperative topographic cylinder between group 1 and group 2 when considering eyes with corneal ectasia <8.0 mm (group 1 A, 4.15 ± 2.19 D [95% CI, 3.64-4.66] vs group 2 A, 3.65 ± 2.13 D [95% CI, 2.92-4.38], p = 0.14); conversely, the difference was significant considering eyes with corneal ectasia ≥8.0 mm (group 1B, 4.74 ± 2.90 D [95% CI, 4.09-5.38] vs group 2B, 3.68 ± 1.94 D [95% CI, 3.10-4.26], p = 0.02). CONCLUSIONS Large 9.0-mm DALK provided better anatomical outcomes compared to conventional 8.0-mm DALK, particularly in eyes with corneal ectasia extending beyond the central 8.0 mm.
Collapse
Affiliation(s)
- Andrea Lucisano
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy.
| | - Andrea Taloni
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Costanza Rossi
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Raffaella Gioia
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| |
Collapse
|
4
|
Basit A, Nafees H, Khan BD, Marwat MZ, Iqbal S, Rehman SA, Abdullah M. Bubbling With Confidence: A Study of Numerous Deep Anterior Lamellar Keratoplasty Cases Using Anwar's Big Bubble Technique. Cureus 2023; 15:e46528. [PMID: 37927665 PMCID: PMC10625428 DOI: 10.7759/cureus.46528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
PURPOSE This study aims to assess the postoperative results, variability, and complications of a hundred deep anterior lamellar keratoplasty cases. Study design and duration: This is an observational study. The study was conducted at Pak International Medical College (PIMC) for a duration of four years (January 2019-January 2023). METHODOLOGY Our study collected information on a hundred cases of deep anterior lamellar keratoplasty (DALK) utilizing Anwar's big bubble technique, consisting of patients with keratoconus, superficial corneal scars, and macular dystrophy. Consenting patients had their pre and postoperative visual acuities and keratometry readings recorded. Overall success and complications were recorded and compared with the present literature. RESULTS Big bubble formation was achieved in 87% (n = 87) eyes and not achieved in 13% (n=13). There was a significant reduction in keratometry values after the procedures as well as improved vision in all patients, with 84% reporting significant improvement. Descemet membrane exposure was achieved in 91% (n=91). Complications included the failure of Anwar's big bubble formation in 13% (n=13) patients and the failure to expose Descemet's in nine patients (9%). CONCLUSION DALK using the big bubble technique is a safe and effective procedure in patients with corneal diseases who have a healthy Descemet membrane and endothelium.
Collapse
Affiliation(s)
- Abdul Basit
- Ophthalmology, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Hamid Nafees
- Ophthalmology, University Hospital Galway, Galway, IRL
| | - Bakht D Khan
- Ophthalmology, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Mir Z Marwat
- Ophthalmology, Pak International Medical College, Peshawar, PAK
| | - Sofia Iqbal
- Ophthalmology, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Saud A Rehman
- Ophthalmology, Jinnah Medical College Peshawar, Peshawar, PAK
| | | |
Collapse
|
5
|
Deshmukh R, Ong ZZ, Rampat R, Alió del Barrio JL, Barua A, Ang M, Mehta JS, Said DG, Dua HS, Ambrósio R, Ting DSJ. Management of keratoconus: an updated review. Front Med (Lausanne) 2023; 10:1212314. [PMID: 37409272 PMCID: PMC10318194 DOI: 10.3389/fmed.2023.1212314] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Keratoconus is the most common corneal ectatic disorder. It is characterized by progressive corneal thinning with resultant irregular astigmatism and myopia. Its prevalence has been estimated at 1:375 to 1:2,000 people globally, with a considerably higher rate in the younger populations. Over the past two decades, there was a paradigm shift in the management of keratoconus. The treatment has expanded significantly from conservative management (e.g., spectacles and contact lenses wear) and penetrating keratoplasty to many other therapeutic and refractive modalities, including corneal cross-linking (with various protocols/techniques), combined CXL-keratorefractive surgeries, intracorneal ring segments, anterior lamellar keratoplasty, and more recently, Bowman's layer transplantation, stromal keratophakia, and stromal regeneration. Several recent large genome-wide association studies (GWAS) have identified important genetic mutations relevant to keratoconus, facilitating the development of potential gene therapy targeting keratoconus and halting the disease progression. In addition, attempts have been made to leverage the power of artificial intelligence-assisted algorithms in enabling earlier detection and progression prediction in keratoconus. In this review, we provide a comprehensive overview of the current and emerging treatment of keratoconus and propose a treatment algorithm for systematically guiding the management of this common clinical entity.
Collapse
Affiliation(s)
- Rashmi Deshmukh
- Department of Cornea and Refractive Surgery, LV Prasad Eye Institute, Hyderabad, India
| | - Zun Zheng Ong
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Radhika Rampat
- Department of Ophthalmology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jorge L. Alió del Barrio
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain
- Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Ankur Barua
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
| | - Marcus Ang
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jodhbir S. Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Dalia G. Said
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Harminder S. Dua
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Renato Ambrósio
- Department of Cornea and Refractive Surgery, Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Darren Shu Jeng Ting
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
6
|
Jamali H, Saluoti R, Maalhagh M, Hosseini S, Shirvani M. Comparison of visual outcomes, keratometric parameters and biomechanical profiles between deep anterior lamellar keratoplasty with big-bubble technique vs. Melles technique for keratoconus: a retrospective study. BMC Ophthalmol 2023; 23:69. [PMID: 36793020 PMCID: PMC9930343 DOI: 10.1186/s12886-023-02816-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE Comparing results of two different DALK surgery techniques (big bubble vs. Melles) in patients with advanced keratoconus. DESIGN a retrospective comparative clinical study. PARTICIPANTS This study conducted on 72 eyes of 72 participants. INTRODUCTION This study designed to compare the results of two different DALK surgery techniques (big bubble vs. Melles) in patients with advanced keratoconus. METHOD Thirty-seven eyes were treated using the big bubble DALK method, while 35 eyes were treated using the Melles approach. Uncorrected visual acuity (UCVA), best corrected spectacle visual acuity (BCSVA), manifest refraction, keratometric characteristics, contrast sensitivity, corneal aberrations, corneal biomechanical characteristics, and endothelial cell profile are the outcome measurements. RESULTS Mean UCVA in big bubble group was 0.61 ± 25 LogMAR and in Melles group was 0.89 ± 0.41 LogMAR (p-value 0.043). Mean BCSVA in big bubble group (0.18 ± 0.12 Log MAR) was significantly better than Melles group (0.35 ± 0.16 Log MAR). Mean of sphere and cylinder refraction showed no significant difference between two groups. Comparing the endothelial cell profile, corneal aberrations, corneal biomechanical properties and keratometry had no significantdifferences. Contrast sensitivity reported as modulation transfer function (MTF) showed higher values in big bubble group and differences with Melles group weresignificant. Results of point spread function (PSF) in big bubble group had superiority to Melles group with considerable statistical P value of 0.023. CONCLUSION When opposed to the Melles approach, the big bubble technique generates a smooth interface with less stromal residue, which results in higher visual quality and contrast sensitivity.
Collapse
Affiliation(s)
- Hossein Jamali
- grid.412571.40000 0000 8819 4698Poostchi Ophthalmology Research Center, Department of Ophthalmology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ramin Saluoti
- grid.412571.40000 0000 8819 4698Poostchi Ophthalmology Research Center, Department of Ophthalmology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrnoosh Maalhagh
- grid.412571.40000 0000 8819 4698Poostchi Ophthalmology Research Center, Department of Ophthalmology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahla Hosseini
- grid.412571.40000 0000 8819 4698Poostchi Ophthalmology Research Center, Department of Ophthalmology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Shirvani
- Poostchi Ophthalmology Research Center, Department of Ophthalmology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. .,Geriatric Ophthalmology Research Center, Shahid sadoughi University of Medical Science, Yazd, Iran.
| |
Collapse
|
7
|
Son HS, Rigi M, Srikumaran D, Eberhart CG, Jun AS, Soiberman US. "Groove and Peel" Deep Anterior Lamellar Keratoplasty: How Deep Can You Go? Cornea 2023; 42:105-109. [PMID: 35965394 DOI: 10.1097/ico.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 06/06/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of the current research was to measure the thickness of the residual central corneal bed after performing the manual "Groove and Peel" deep anterior lamellar keratoplasty (GP-DALK) technique on human cadaveric eyes. METHODS The manual GP-DALK technique was performed on 6 human cadaver eyes by an experienced corneal surgeon. After surgery, the eye globes were fixed in 10% buffered formalin and embedded in paraffin. For each eye, 4-μm-thick hematoxylin and eosin sections involving the pupillary axis were obtained and examined. Using an image-processing software, 2 observers measured the corneal thickness of the residual central corneal bed and the peripheral corneal rims. RESULTS The overall mean central corneal bed thickness was 35.5 ± 12.9 μm, whereas the mean right and left peripheral rim thicknesses were 993.0 ± 141.1 and 989.3 ± 147.1 μm, respectively ( P = 0.0006 ). In most corneas, the level of dissection reached almost to the pre-Descemetic collagen (Dua) layer. CONCLUSIONS The GP-DALK technique is effective in removing most of the corneal stroma and may be non-inferior to "big-bubble" deep anterior lamellar keratoplasty in some cases.
Collapse
Affiliation(s)
- Hyeck-Soo Son
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, MD; and
- Department of Ophthalmology, University of Heidelberg, Heidelberg, Baden-Wuerttemberg, Germany
| | - Mohammed Rigi
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, MD; and
| | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, MD; and
| | - Charles G Eberhart
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, MD; and
| | - Albert S Jun
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, MD; and
| | - Uri S Soiberman
- Wilmer Eye Institute, Johns Hopkins Medical Institutions, Baltimore, MD; and
| |
Collapse
|
8
|
Lisa C, Machado Soares R, Fernández-Vega-Cueto L, Alfonso-Bartolozzi B, Alfonso JF. Modified Deep Anterior Lamellar Keratoplasty Technique to Rescue Failed Penetrating Keratoplasty. Clin Ophthalmol 2022; 16:3741-3749. [DOI: 10.2147/opth.s382916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022] Open
|
9
|
Arora R, Gupta I, Sahu J, Vishwanath S, Gupta P, Jain P. Corneal aberrations, densitometry on scheimpflug imaging, and visual acuity after deep anterior lamellar keratoplasty. Eur J Ophthalmol 2022; 33:11206721221128863. [PMID: 36172635 DOI: 10.1177/11206721221128863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate visual acuity, corneal aberrations, and densitometry post deep anterior lamellar keratoplasty (DALK). METHODS Twenty-five eyes of 25 patients who underwent DALK for corneal stromal diseases with normal endothelium were enrolled in a prospective interventional study. Evaluation for corneal aberrations and densitometry postoperatively was performed using Scheimpflug imaging at 6 months. Anterior Segment Optical Coherence Tomography (ASOCT) was done for host-graft morphology. Correlation analysis of postoperative best-corrected visual acuity with corneal aberrations and corneal densitometry (CD) was performed. RESULTS Big bubble deep anterior lamellar keratoplasty (BB-DALK) was successful in 18 patients, while 7 eyes underwent manual dissection due to failed BB (Big Bubble) technique. The mean BSCVA was 1.35 ± 0.46 logMAR units pre-operatively which improved to 0.36 ± 0.19 logMAR units post DALK at 6 months (P < 0.001). The mean Root Mean Square (RMS) (μm) of the magnitude of total corneal aberrations, HOA and LOA from central 6mm zone of cornea were 14.6 ± 9.2, 4.7 ± 2.9, and 13.8 ± 8.8, respectively. The mean anterior (120μm), central and posterior corneal (60μm) densitometry in 0-2mm zone were 25.8 ± 7.7 GSU, 18.7 ± 4.16 GSU and 10.09 ± 3.9 GSU respectively. A statistically significant correlation of postoperative residual stromal bed thickness, total corneal HOA, LOA, total corneal aberrations, HOA front and posterior corneal densitometry (0-2mm zone) with postoperative BSCVA was found. CONCLUSION Though there is a significant improvement in BSCVA after DALK, the quality of vision in terms of aberrometry and densitometry is suboptimal, especially in cases undergoing manual DALK compared to those undergoing big bubble formation.
Collapse
Affiliation(s)
- Ritu Arora
- Department of Ophthalmology (76300Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Isha Gupta
- Department of Ophthalmology (76300Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Jigyasa Sahu
- Department of Ophthalmology (76300Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Shweta Vishwanath
- Department of Ophthalmology (76300Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Palak Gupta
- Department of Ophthalmology (76300Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Parul Jain
- Department of Ophthalmology (76300Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| |
Collapse
|
10
|
Vanathi M, Raj N, Kusumesh R, Aron N, Gupta N, Tandon R. Update on Pediatric Corneal Diseases and Keratoplasty. Surv Ophthalmol 2022; 67:1647-1684. [PMID: 35918016 DOI: 10.1016/j.survophthal.2022.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 10/31/2022]
Abstract
Managing pediatric corneal disorders is challenging as the prognosis of pediatric keratoplasty depends on several factors. Advancements in the genetic basis of congenital corneal diseases and investigations in congenital corneal conditions provide a better understanding of pediatric corneal conditions. Surgeons performing keratoplasty in children now have a choice of various techniques. Evolving surgical techniques of anterior lamellar and endothelial keratoplasties has expanded the management interventions in these pediatric corneal morbidity conditions; however, considerable concerns still exist in association with corneal transplantation in infants and children. Outcomes in pediatric keratoplasty depend upon the preoperative indications, the timing of surgical intervention, intraoperative and postoperative factors including the patient/care givers' compliance. Factors such as low scleral rigidity, higher rate of graft failure, need for frequent examinations under anesthesia, and difficulty in optimal visual acuity assessment still remain a considerable challenge in pediatric scenarios. In children, deprivation amblyopia as a result of the corneal opacification can adversely affect visual development, causing dense amblyopia. Outcomes to surgical interventions for management of corneal opacification in children is further compromised by the pre-existing amblyopia apart from the concerns of refractive outcome of the graft. Graft rejection, graft infection, amblyopia, and glaucoma continue to be serious concerns. In recent years both anterior and posterior lamellar keratoplasty techniques are being increasingly performed in pediatric eyes, which offer advantages in the form of lower risk of graft rejection. The timing of surgery, careful case selection, cautious intraoperative approach, and optimal postoperative management can improve the anatomical and functional outcome in difficult cases.
Collapse
Affiliation(s)
- Murugesan Vanathi
- Cornea, Lens & Refractive Services, Dr. R P Centre for Ophthalmic Sciences - ALL INDIA INSTITUTE OF MEDICAL SCIENCES, New Delhi 110029, India.
| | - Nimmy Raj
- Cornea, Lens & Refractive Services, Dr. R P Centre for Ophthalmic Sciences - ALL INDIA INSTITUTE OF MEDICAL SCIENCES, New Delhi 110029, India
| | - Rakhi Kusumesh
- Cornea & Ocular Surface Services, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Neelima Aron
- Cornea, Lens & Refractive Services, Dr. R P Centre for Ophthalmic Sciences - ALL INDIA INSTITUTE OF MEDICAL SCIENCES, New Delhi 110029, India
| | - Noopur Gupta
- Cornea, Lens & Refractive Services, Dr. R P Centre for Ophthalmic Sciences - ALL INDIA INSTITUTE OF MEDICAL SCIENCES, New Delhi 110029, India
| | - Radhika Tandon
- Cornea, Lens & Refractive Services, Dr. R P Centre for Ophthalmic Sciences - ALL INDIA INSTITUTE OF MEDICAL SCIENCES, New Delhi 110029, India
| |
Collapse
|
11
|
Hashish AM, El-Awady HE, Sabry DM, Awad EA. Assessment of Corneal Densitometry in Big-Bubble Dissection Versus Manual Dissection Deep Anterior Lamellar Keratoplasty. Cornea 2022; 41:593-597. [PMID: 34907941 DOI: 10.1097/ico.0000000000002815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/23/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to assess corneal densitometry and visual outcomes after big-bubble deep anterior lamellar keratoplasty (BB-DALK) and manual dissection deep anterior lamellar keratoplasty in patients with keratoconus. METHODS This retrospective comparative observational study included 40 keratoconic patients who underwent DALK surgery: 22 eyes had BB-DALK (group I) and 18 eyes had failed BB technique and DALK was completed by manual dissection (group II). Best -corrected visual acuity (BCVA), corneal topographic parameters, residual stromal tissue thickness, and endothelial cell count were recorded at 1, 3, 6, and 12 months postoperatively. Densitometric analysis of different corneal layers and zones was performed using Scheimpflug tomography at each visit; values were recorded and compared between the 2 groups. RESULTS At 1 and 6 months postoperatively, BCVA was better in group I than in group II, but with no statistically significant difference. At 12 months, the visual acuities became nearly similar in both groups (0.30 ± 0.13 vs. 0.30 ± 0.14 logarithm of the minimum angle of resolution, P = 0.888). Regarding corneal densitometric analysis, the recorded values for the posterior corneal layer were significantly higher in group II compared with group I at 3, 6, 9, and 12 months postoperatively in the 0- to 2-mm zone (P < 0.001) and the 2- to 6-mm zone (P = 0.029, 0.028, 0.001, and <0.001). CONCLUSIONS Manual dissection DALK after failed BB technique may affect the interface stromal reflectivity up to 12 months postoperatively. However, this does not significantly affect the visual acuity in comparison with successful BB-DALK.
Collapse
Affiliation(s)
- Aya M Hashish
- Department of Ophthalmology, Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | | | | |
Collapse
|
12
|
Femtosecond laser-assisted big bubble for deep anterior lamellar keratoplasty. J Cataract Refract Surg 2021; 47:106-110. [PMID: 32932372 DOI: 10.1097/j.jcrs.0000000000000400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the utility of a femtosecond laser-assisted stromal channel to assist the creation of a big bubble (BB) for deep anterior lamellar keratoplasty (DALK) surgery in cadaveric corneas. SETTING L V Prasad Eye Institute, Hyderabad, India. DESIGN Experimental study. METHODS An attempt to create a BB was made on 10 donor pairs of human cadaveric corneoscleral tissues. The 20 corneas were split into 2 groups: Group A underwent femtosecond laser pretreatment and Group B had conventional manual deep lamellar technique. Laser pretreatment was performed using the VisuMax femtosecond laser system to create a stromal channel using the intracorneal ring segment treatment module for direct insertion of the 27-gauge air cannula for pneumodissection at a predetermined depth. RESULTS Of the 20 corneas studied, type 1 BB was achieved in 9 of 10 corneas in Group A and in 7 of 10 corneas in Group B. One cornea from Group A had a combined type 1 and 2 BB, whereas no BB was achieved in 1 cornea. CONCLUSIONS Creation of an intrastromal channel using a femtosecond laser at a predetermined depth seemed to be a promising option to increase the chances of achieving a BB when compared with the conventional air injection technique of BB DALK.
Collapse
|
13
|
Fogla R, Sahay P, Sharma N. Preferred practice pattern and observed outcome of deep anterior lamellar keratoplasty - A survey of Indian corneal surgeons. Indian J Ophthalmol 2021; 69:1553-1558. [PMID: 34011739 PMCID: PMC8302320 DOI: 10.4103/ijo.ijo_3067_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 01/20/2023] Open
Abstract
Purpose This study aimed to assess the preferred surgical technique and outcome of deep anterior lamellar keratoplasty (DALK) among corneal surgeons in India. Methods An online questionnaire-based cross-sectional survey was conducted among members of the Cornea Society of India (CSI) with experience of performing >10 DALK procedure. The responses pertaining to their surgical experience, preferred technique, complications, and outcome of DALK were collected and analyzed. Results A total of 156 responses were received. In total, 35.9% of participants reported annual keratoplasty of >50, and DALK constituted >25% surgeries for 25% of participants. Ectatic corneal disorder was reported as the most common indication for DALK by 71.6% of the respondents. Big-bubble (BB) DALK (WA-1.82) was the most preferred technique, along with suction trephine (50%) for partial trephination and bottom port cannula (45.5%) for BB formation. On statistical analysis, no difference was observed in the surgeon reported success rate of BB formation with or without anterior lamellar keratectomy (ALK) (χ2 (1,156) = 3.1498, P = 0.08) or paracentesis (χ2 (1,156) = 0.2737, P = 0.60) before stromal air injection, and method of stromal air injection (χ2 (1,156) = 4.7325, P = 0.09). Conversion to penetrating keratoplasty was reported by 16% of participants in >25% cases, while 66.7% reported in <10% cases. Cataract and double anterior chamber were the most common complications. 50% of participants suggested that >20 procedures are required to overcome the learning curve. Conclusion BB DALK is the most commonly practiced DALK technique, and its success is independent of ALK and paracentesis being performed prior to air injection and method of air injection (cannula/needle).
Collapse
Affiliation(s)
- Rajesh Fogla
- Cornea Clinic, Apollo Hospitals, Hyderabad, India
| | - Pranita Sahay
- Department of Ophthalmology, Lady Hardinge Medical College, New Delhi, India
| | - Namrata Sharma
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
14
|
Li F, Zhang L, Zhou Y, Zhu D. Modified deep anterior lamellar dissection for corneal opacity during vitrectomy: case reports. BMC Ophthalmol 2020; 20:317. [PMID: 32746804 PMCID: PMC7398210 DOI: 10.1186/s12886-020-01587-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/28/2020] [Indexed: 11/24/2022] Open
Abstract
Background To introduce a modified deep anterior lamellar dissection technique to improve visibility during surgery for vitreoretinal diseases with coexisting corneal opacity. Case presentation Two patients with retinal detachment and coexisting corneal blood staining or corneal decompensation underwent modified deep anterior lamellar dissections followed by vitrectomy. The modified deep anterior lamellar dissection techniques, unlike the dissection and removal of corneal lamellar in a typical deep anterior lamellar keratoplasty, included the creation and preservation of a deep lamellar corneal flap, the retroillumination to visualize and easily remove the remaining opaque stroma on the Descemet membrane, and the big air bubble technique in the eye with endothelial decompensation. The patient’s own cornea flap was sutured back after vitrectomy was done. The modified dissection techniques provided adequate fundus view during vitrectomy while removing as less corneal tissue as possible and decreasing the surgical complications and the requirement of a fresh cornea. Postoperatively, in case 1, the corneal blood staining was gradually absorbed and the vision improved from light perception to counting fingers. In case 2, even though the cornea remained cloudy and the vision was poor, the cornea endothelial decompensation was stable and asymptomatic. Both retinas were attached after silicone oil removal at 6-month follow-up. Conclusions This modified and limited deep anterior lamellar corneal dissection procedure appears to be a useful alternative to penetrating keratoplasty, ophthalmic endoscope and temporary keratoprosthesis during the vitrectomy with coexisting corneal opacity.
Collapse
Affiliation(s)
- Fang Li
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200011, China.,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Leilei Zhang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200011, China.,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Yixiong Zhou
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200011, China.,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Dongqing Zhu
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200011, China. .,Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China.
| |
Collapse
|
15
|
Scorcia V, Giannaccare G, Lucisano A, Soda M, Scalzo GC, Myerscough J, Pellegrini M, Verdoliva F, Piccoli G, Bovone C, Busin M. Predictors of Bubble Formation and Type Obtained With Pneumatic Dissection During Deep Anterior Lamellar Keratoplasty in Keratoconus. Am J Ophthalmol 2020; 212:127-133. [PMID: 31883463 DOI: 10.1016/j.ajo.2019.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/26/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify predictors of bubble formation and type during big-bubble deep anterior lamellar keratoplasty (BB-DALK) performed in keratoconus at different stages of severity. DESIGN Retrospective Cohort Study. METHODS Setting: University Magna Græcia (Catanzaro, Italy); Study Population: Consecutive keratoconus patients undergoing BB-DALK from September 2014 to February 2019. OBSERVATION PROCEDURE Keratometric astigmatism, mean keratometry value (K-mean), highest keratometry value (K-max), thinnest point, anterior segment optical coherence tomography (AS-OCT)-based stage of ectasia. MAIN OUTCOME MEASURES Rate of bubble formation and type; number and fate of micro-/macroperforation; conversion to mushroom keratoplasty (MK); comparison of parameters in patients with bubble formation vs failure and in type 1 vs type 2 bubble; areas under the curves (AUC) of preoperative parameters for distinguishing between bubble types. RESULTS Pneumatic dissection succeeded in 113 of 155 eyes (72.9%), with 100 type 1 bubbles (88.4%), 11 type 2 (9.8%), and 2 mixed-type (1.8%). Microperforations were managed conservatively in type 1 bubbles; macroperforations occurring in both types of bubbles required conversion to MK. Preoperative K-mean and K-max values were significantly higher in eyes in which bubble formation succeeded (respectively, P = .006 and P < .013). Type 1 bubbles formed in eyes with significantly lower age, K-mean, and AS-OCT stages and higher pachymetric values (always P < .029). Age had the highest diagnostic power for discrimination between bubble types, followed by AS-OCT stage, pachymetry, K-mean, and astigmatism (respectively, AUC = 0.861, 0.779, 0.748, 0.700, 0.670). CONCLUSIONS Older age and advanced stages of keratoconus were predictors of type 2 bubble formation during BB-DALK that was associated with an increased risk of complications.
Collapse
Affiliation(s)
- Vincenzo Scorcia
- Department of Ophthalmology, University Magna Græcia, Catanzaro, Italy; Istituto Internazionale per la Ricerca in Oftalmologia (IRFO), Forlì, Italy.
| | | | - Andrea Lucisano
- Department of Ophthalmology, University Magna Græcia, Catanzaro, Italy
| | - Mauro Soda
- Department of Ophthalmology, University Magna Græcia, Catanzaro, Italy
| | | | | | - Marco Pellegrini
- Ophthalmology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | - Gabriele Piccoli
- Department of Ophthalmology, University Magna Græcia, Catanzaro, Italy
| | - Cristina Bovone
- Istituto Internazionale per la Ricerca in Oftalmologia (IRFO), Forlì, Italy; Ospedale Privato Villa Igea, Forlì, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Massimo Busin
- Istituto Internazionale per la Ricerca in Oftalmologia (IRFO), Forlì, Italy; Ospedale Privato Villa Igea, Forlì, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| |
Collapse
|
16
|
Ceylanoglu KS, Aydin B, Ozmen MC. Comparison of clinical outcomes of deep anterior lamellar keratoplasty and excimer laser assisted anterior lamellar keratoplasty in keratoconus. Int J Ophthalmol 2019; 12:582-586. [PMID: 31024810 DOI: 10.18240/ijo.2019.04.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 09/30/2018] [Indexed: 11/23/2022] Open
Abstract
AIM To compare and evaluate the clinical outcomes of deep anterior lamellar keratoplasty (DALK) and excimer laser assisted anterior lamellar keratoplasty (ELLK) in eyes with keratoconus. METHODS In this study, 57 eyes of 56 patients operated between 2013 to 2017 were included. Thirty-one eyes underwent big-bubble DALK and twenty-six eyes underwent ELLK. Preoperative and at control visits complete ophthalmic examination was performed. RESULTS The mean patient age at the time of DALK surgery was 27y and mean follow-up period was 21±5.4mo. The mean patient age at the time of ELLK surgery was 27y and mean follow-up period was 40±18mo. Mean best spectacle corrected visual acuity (BSCVA) at postoperative period was significantly higher for DALK group (0.66±0.11) versus ELLK group (0.4±0.2) (P<0.05). Descemet's membrane microperforation was occurred in 7 patients in DALK group versus in 1 patient in ELLK group. In 4 eyes, interface irregularity was developed in ELLK group. None of the patients in follow-up had graft rejection in both groups. CONCLUSION In ELLK group, complication rate is lower, the surgical technique is simpler, faster and safer and also ELLK requires less experience with respect to DALK. Further, DALK can be performed unless satisfactory visual acuity is achieved after ELLK.
Collapse
Affiliation(s)
| | - Bahri Aydin
- Department of Ophthalmology, Gazi University Medical School, Yenimahalle, Ankara 06500, Turkey
| | - Mehmet Cuneyt Ozmen
- Department of Ophthalmology, Gazi University Medical School, Yenimahalle, Ankara 06500, Turkey
| |
Collapse
|
17
|
Blunt Scissors Stromal Dissection Technique Compared With Big-Bubble Deep Anterior Lamellar Keratoplasty. Eye Contact Lens 2019; 45:195-200. [PMID: 30741777 DOI: 10.1097/icl.0000000000000557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the clinical findings and results of new modified manual deep anterior lamellar keratoplasty (M-DALK) technique compared with a big-bubble DALK (BB-DALK) technique in eyes with corneal scars or lesions. METHODS A prospective, nonrandomized, comparative study included 65 eyes of 65 patients treated by M-DALK using the blunt scissors lamellar dissection technique or standard BB-DALK. Visual acuity, endothelial cell density, corneal cylinder (Cyl), central corneal thickness (CCT), residual stromal thickness and aberrometric values were recorded pre-treatment and 1, 3, 6, 12 and 18 months after treatment. RESULTS Thirty-five eyes of 35 patients underwent deep anterior lamellar keratoplasty (DALK) with successful big-bubble technique, whereas 30 eyes of 30 patients underwent DALK with manual technique (in 10 eyes as a primary technique, in 20 eyes as a secondary technique). Successful big-bubble formation was achieved in 35 of 55 (64%) eyes. Microperforations occurred in three eyes in BB-DALK group, in six eyes in M-DALK group, and DALK could be completed successfully in these eyes. Visual acuity and endothelial cell loss results were not significantly different between groups during follow-up period. Mean CCT was significantly different between groups (P=0.035). Mean corneal Cyl, residual stromal thickness, and aberrometric values were similar between groups (P>0.05) at the final visit. CONCLUSION New modified M-DALK technique has similar clinical findings and results with BB-DALK when using as a primary or secondary approach.
Collapse
|
18
|
Evaluation of Big Bubble Technique for Deep Anterior Lamellar Keratoplasty in Patients With Radial Keratotomy. Cornea 2018; 38:194-197. [PMID: 30431472 DOI: 10.1097/ico.0000000000001811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the outcome of deep anterior lamellar keratoplasty (DALK) and success rates of the big-bubble (BB) technique or manual dissection after a failed use of the BB technique in eyes that underwent prior radial keratotomy (RK). METHODS A retrospective chart review of patients who underwent DALK after RK at Toronto Western Hospital, Canada, between 1999 and 2017 was performed. Demographic characteristics, success rates of the BB technique and manual dissection, intraoperative and postoperative complications, and best spectacle-corrected visual acuity before and after corneal transplant were analyzed. RESULTS Ten eyes of 9 patients were included in the analysis. The average age was 64 ± 10 years (range 49-82). The average time between the RK surgery and the corneal transplant was 20 ± 5 years (range 8-24). Indications for corneal transplant were significant irregular astigmatism in 5 eyes (50%), central scarring or haze in 4 eyes (40%), and progressive hyperopia with visual fluctuation in one eye (10%). BB was successfully achieved in one eye (10%). In 6 eyes (60%), manual dissection was performed, and in 3 eyes (30%), DALK surgery was converted to penetrating keratoplasty. The average best spectacle-corrected visual acuity on the last follow-up visit was 0.26 ± 0.08 logMAR (Snellen equivalent 20/36). One eye that underwent manual DALK and one eye that underwent penetrating keratoplasty developed a rejection episode 4 and 2 months after keratoplasty, respectively. In both cases, rejection resolved with topical steroids. CONCLUSIONS In eyes that underwent prior RK, DALK by manual dissection should be considered as a preferable surgical technique.
Collapse
|
19
|
Kodavoor SK, Deb B, Ramamurthy D. Outcome of deep anterior lamellar keratoplasty patients with intraoperative Descemet's membrane perforation: A retrospective cross-sectional study. Indian J Ophthalmol 2018; 66:1574-1579. [PMID: 30355864 PMCID: PMC6213700 DOI: 10.4103/ijo.ijo_282_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate functional and anatomical outcome in patients undergoing deep anterior lamellar keratoplasty (DALK) with intraoperative Descemet's membrane (DM) perforation (macro and micro). METHODS A retrospective cross sectional study (January 2009 to December 2015) of sixteen eyes of sixteen patients which included nine patients of advanced keratoconus (KC), two patients with paracentral DM scarring post hydrops, KC with Bowman's membrane scarring, macular corneal dystrophy and one patient of advanced Pellucid Marginal Degeneration (PMD). All underwent DALK with intraoperative DM perforation. Big bubble technique was attempted in all except in the two patients with post hydrops DM scar. Preoperative and postoperative best corrected visual acuity (BCVA), astigmatism and endothelial count (EC) were compared. RESULTS Postoperative BCVA and astigmatism were found to be better and statistically significant ('p value' 0.00 and 0.003 respectively). BCVA preoperative and postoperative was 1.07± 0.3 and 0.28 ± 0.09 in LogMAR respectively and astigmatism pre and postoperative 4.14 ± 1.5 D and 2.7 ± 0.97 D respectively. Percentage decrease in EC at sixth postoperative week was 7.48% and at sixth month and 1 year postoperative was 15.1%. Two patients developed postoperative double anterior chamber and two patients developed pupillary block glaucoma and all were successfully managed. CONCLUSION Not all patients of intraoperative DM perforation (including macro perforation) needs to be converted to penetrating keratoplasty. DALK can be successfully done if the perforation is identified early and managed adequately. This is the only known study which has shown a large series of successful DALK even with macro perforations.
Collapse
Affiliation(s)
- Shreesha Kumar Kodavoor
- Department of Cornea, Cataract and Refractive Services, The Eye Foundation Hospital, Coimbatore, Tamil Nadu, India
| | - Bijita Deb
- Department of Cornea, Cataract and Refractive Services, The Eye Foundation Hospital, Coimbatore, Tamil Nadu, India
| | - Dandapani Ramamurthy
- Department of Cornea, Cataract and Refractive Services, The Eye Foundation Hospital, Coimbatore, Tamil Nadu, India
| |
Collapse
|
20
|
|
21
|
Elbaz U, Kirwan C, Shen C, Ali A. Avoiding big bubble complications: outcomes of layer-by-layer deep anterior lamellar keratoplasty in children. Br J Ophthalmol 2018; 102:1103-1108. [PMID: 29301767 DOI: 10.1136/bjophthalmol-2017-310962] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/28/2017] [Accepted: 12/22/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS To describe the visual and clinical outcomes of manual layer-by-layer deep anterior lamellar keratoplasty (DALK) in a paediatric population. METHODS The charts of all children who underwent DALK surgery between January 2007 and January 2015 were reviewed retrospectively. Data collected included preoperative and postoperative spectacle-corrected distance visual acuity (CDVA), intraoperative and postoperative complications including graft rejection and failure. Residual posterior lamellar thickness (RPLT) and endothelial cell density (ECD) were measured in eyes with follow-up longer than 6 months. RESULTS Fifty-one eyes of 42 patients were included in the study. The mean patient age at surgery was 11.2±5.2 years and the mean follow-up time was 36.5±23.7 months. The most common indications for surgery were mucopolysaccharidosis (29.4%) and keratoconus (23.5%). Nine eyes (17.6%) had intraoperative microperforation, none of which were converted to penetrating keratoplasty (PKP). Only one eye (2.0%) was converted to PKP. Five eyes (9.8%) had a stromal rejection episode of which one eye failed. Another four eyes (7.8%) experienced graft failure among which three eyes (75%) had infectious keratitis. Three of the five failed grafts had a successful repeat DALK. The average RPLT was 81.9±36.5μm. ECD was significantly lower in the operated eye compared with the normal eye (3096±333 cells/mm2 vs 3376±342 cells/mm2, n=11, P=0.003). The mean postoperative CDVA was 0.5±0.4 logarithm of the minimum angle of resolution (logMAR) reflecting a gain of 0.3 logMAR (P<0.001). CONCLUSION Manual dissection DALK is a safe procedure in children with stromal opacities. Despite successful structural rehabilitation, functional recovery is still suboptimal mostly due to amblyopia.
Collapse
Affiliation(s)
- Uri Elbaz
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Caitriona Kirwan
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carl Shen
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Large (9 mm) Deep Anterior Lamellar Keratoplasty with Clearance of a 6-mm Optical Zone Optimizes Outcomes of Keratoconus Surgery. Ophthalmology 2017; 124:1072-1080. [DOI: 10.1016/j.ophtha.2017.02.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/20/2022] Open
|
23
|
Hesse M, Kuerten D, Walter P, Plange N, Johnen S, Fuest M. The effect of air, SF6 and C3F8 on immortalized human corneal endothelial cells. Acta Ophthalmol 2017; 95:e284-e290. [PMID: 27595913 DOI: 10.1111/aos.13256] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/31/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE While anterior chamber air bubbles aid attachment during posterior lamellar surgery only for few days, these periods can be prolonged with gases in non-expanding concentrations. To test the effects of different gas compositions on immortalized human corneal endothelial cells (HCEC-12), we utilized Transwell inserts with semipermeable membranes as an artificial anterior chamber model. METHODS Human corneal endothelial cells (HCEC-12) were cultured on Transwell inserts for 24 hr, then flipped, burdened and sunk with titanium rings in medium (M1), as well as filled with 2 ml of air (A), 20% sulphur hexafluoride (SF6) (S), or 12% C3F8 (C). After gas exposition for 24, 48 and 120 hr, cells were evaluated by live/dead staining, cell viability assay and Ki67 immunohistochemistry. RESULTS Proliferation was significantly reduced (Ki67-positive fraction; M1, 14.8 ± 2.0%; A, 7.9 ± 1.4%; S, 8.1 ± 1.3%; C, 9.9 ± 2.3%; p-values; A, S, C versus M1 < 0.01), the total cell number decreased and the percentage of dead cells increased under gas exposition, independently of the type of gas (120 hr cell count/2.25 cm2 : M1 = 660.8 ± 57.0 cells; A = 125.5 ± 17.4 cells, S = 123.5 ± 17.0 cells, C = 118.8 ± 16.6 cells; p-value: M versus A/S/C < 0.001; 120 hr dead cells: M = 2.6 ± 1.0%, A = 8.4 ± 2.7%, S = 9.5 ± 3.2%, C = 11.3 ± 3.1%; p-value: M1 versus A/S/C < 0.01). Medium (M1)-control also proved significantly higher cell viability values in comparison with the gases, which did not differ significantly among them (120 hr luminescence: M1 = 1752.2 ± 91.4, A = 433.0 ± 30.3, S = 507.8 ± 23.3, C = 523.8 ± 20.3; p-value: M1 versus A/S/C < 0.01). CONCLUSIONS Gas exposition led to a reduction in proliferation and an increase in cell death in HCEC-12, independently of the gas composition.
Collapse
Affiliation(s)
- Marina Hesse
- Department of Ophthalmology; RWTH Aachen University; Aachen Germany
| | - David Kuerten
- Department of Ophthalmology; RWTH Aachen University; Aachen Germany
| | - Peter Walter
- Department of Ophthalmology; RWTH Aachen University; Aachen Germany
| | - Niklas Plange
- Department of Ophthalmology; RWTH Aachen University; Aachen Germany
| | - Sandra Johnen
- Department of Ophthalmology; RWTH Aachen University; Aachen Germany
| | - Matthias Fuest
- Department of Ophthalmology; RWTH Aachen University; Aachen Germany
| |
Collapse
|
24
|
Ho YJ, Wu CH, Chen HC, Hsiao CS, Hsueh YJ, Ma DHK. Surgical outcome of deep anterior lamellar keratoplasty with air-assisted manual dissection for corneas with previous inflammation or fibrosis. Taiwan J Ophthalmol 2017; 7:191-198. [PMID: 29296551 PMCID: PMC5747229 DOI: 10.4103/tjo.tjo_13_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE: To report our experience in air-assisted manual dissection deep anterior lamellar keratoplasty (DALK) for the treatment of corneal scar with previous inflammation and fibrosis. MATERIALS AND METHODS: We retrospectively reviewed the medical history of 21 patients (male:female = 13:8 mean age 41.9 years old) with corneal pathology from previous infection and inflammation. Trephination diameter ranged from 7.0 to 8.0 mm, and the graft was oversized by 0.25–0.50 mm. Debulking technique was performed to expose Descemet's membrane after filling stroma with air. Starting from postoperative 3 months, selective suture removal was performed to reduce corneal astigmatism. RESULTS: The mean follow-up period was 59.9 ± 19.8 (20–96) months. Intraoperative microperforation occurred in 2 eyes (9.5%); however, there was no shift to penetrating keratoplasty. Air-bubble tamponade was performed in 7 eyes (33.3%) for postoperative gapping of the graft. There were 2 failed grafts (9.5%) due to corneal ulcer while all the other grafts remained clear throughout follow-up. The mean preoperative best-corrected visual acuity (BCVA) was 1.84 ± 0.66 logMAR, which improved to 0.74 ± 0.63 (P < 0.01). The average sphere power was − 0.88 ± 3.88 diopter (D), average cylinder power 3.03 ± 1.46D, and average endothelial count 1877 ± 375 cells/mm2. CONCLUSION: In severe ocular surface diseases, big-bubble technique frequently failed to separate predescemtic plane; however, it effectively created air-filled stroma which was easier to remove. Although BCVA was suboptimal due to ocular surface disorders, graft survival and clarity rate is high, justifying the application of DALK in these cases.
Collapse
Affiliation(s)
- Yi-Ju Ho
- Department of Ophthalmology, Limbal Stem Cell Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Cheng-Hsiu Wu
- Department of Ophthalmology, Lo-Hsu Medical, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Lotung, Taiwan
| | - Hung-Chi Chen
- Department of Ophthalmology, Limbal Stem Cell Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chin-Shi Hsiao
- Department of Ophthalmology, Limbal Stem Cell Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yi-Jen Hsueh
- Department of Ophthalmology, Limbal Stem Cell Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - David Hui-Kang Ma
- Department of Ophthalmology, Limbal Stem Cell Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Chinese Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
| |
Collapse
|
25
|
Outcomes of Air Injection Within 2 mm Inside a Deep Trephination for Deep Anterior Lamellar Keratoplasty in Eyes With Keratoconus. Am J Ophthalmol 2016; 170:239. [PMID: 27544043 DOI: 10.1016/j.ajo.2016.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/19/2016] [Indexed: 11/21/2022]
|
26
|
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]
|
27
|
Godefrooij DA, Gans R, Imhof SM, Wisse RP. Trends in penetrating and anterior lamellar corneal grafting techniques for keratoconus: a national registry study. Acta Ophthalmol 2016; 94:489-93. [PMID: 27061780 DOI: 10.1111/aos.13041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 02/04/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Keratoconus is a progressive disorder and one of the primary indications for corneal transplantation. Anterior lamellar keratoplasty offers several advantages over other techniques, including endothelial preservation and longer graft survival. In this study, we examined the recent trend of using lamellar techniques for keratoconus at a national level. METHODS Data were obtained from the Dutch national organ transplant database regarding corneal transplants for keratoconus performed in 2005 through 2014. Baseline characteristics for patients undergoing various techniques were obtained, and temporal trends were analysed. RESULTS A total of 1041 operations were performed, including 736 penetrating keratoplasties (PKPs) and 297 anterior lamellar keratoplasties (ALKs). The mean age of the total surgical group was 37.4 ± 13.4 years, and 68% of patients were male (p = 0.0001). Preoperative patient characteristics were reported in all 1041 cases. The relative proportion of ALKs increased from 2005 (19% of cases) to 2010 (39% of cases) and remained approximately 30-40% thereafter. Descemet baring or deep anterior lamellar keratoplasty (DALK) was increasingly applied and was the predominant anterior lamellar technique performed from 2009 onwards. CONCLUSIONS The number of corneal transplantations performed annually for keratoconus decreased during the past 10 years. Lamellar techniques were increasingly performed, accounting for approximately 35% of keratoplasties in 2010 and thereafter. Among ALK techniques, maximal depth DALK is the most prevalent keratoplasty performed for keratoconus in most recent years. Penetrating keratoplasty (PKP) is still common, with a stable frequency from 2010 onwards.
Collapse
Affiliation(s)
- Daniel A. Godefrooij
- Utrecht Cornea Research Group; Department of Ophthalmology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Renze Gans
- Utrecht Cornea Research Group; Department of Ophthalmology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Saskia M. Imhof
- Utrecht Cornea Research Group; Department of Ophthalmology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Robert P.L. Wisse
- Utrecht Cornea Research Group; Department of Ophthalmology; University Medical Center Utrecht; Utrecht The Netherlands
| |
Collapse
|
28
|
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.
Collapse
|
29
|
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.
Collapse
|
30
|
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]
|