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Abusayf MM, Liu YC, Han E, Yu ILX, Riau AK, Mehta JS. One-Step Intraoperative Optical Coherence Tomography Guided Tunnel, Mushroom Femtosecond Laser Big Bubble Deep Anterior Lamellar Keratoplasty. Bioengineering (Basel) 2024; 11:639. [PMID: 39061721 PMCID: PMC11273850 DOI: 10.3390/bioengineering11070639] [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: 05/02/2024] [Revised: 06/15/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of our study is to investigate the feasibility and outcomes of using a femtosecond laser (FSL) platform (Ziemer LDV Z8) for deep anterior lamellar keratoplasty (DALK), enabling the creation of mushroom-shaped graft-host junctions, lamellar cuts, and intrastromal tunnels, to facilitate the big bubble, in one step. We included wet lab experiments on nine porcine eyes to assess the laser accuracy and cuts depth using an anterior segment (AS) OCT. This was followed by an interventional prospective case series on 10 eyes with variant corneal pathologies. The Z8 system, with in-built intraoperative optical coherence tomography (iOCT), guided corneal scans and directed the cuts. ASOCT showed visible mushroom configurations, lamellar cuts, and tunnels. Deviations from the target were 1.6%, 2.6%, and 3.5%. Anterior lamellar removal was easy in all clinical cases, including corneal scarring. The intrastromal tunnel was found at the preset location and the mushroom configuration was acquired. A big bubble was achieved in all cases. Type 1, 2, and 3 bubbles were formed in eight, one, and one case, respectively. We describe a new approach to DALK in which the in-built iOCT-guided FSL enables safe, precise, controlled, and reproducible desired cuts in one step. The preliminary clinical outcomes were favorable.
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Affiliation(s)
- Mohammed M. Abusayf
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
- Cornea and External Eye Disease Service, Singapore National Eye Center, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
| | - Yu-Chi Liu
- Cornea and External Eye Disease Service, Singapore National Eye Center, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
| | - Evelina Han
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
| | - Isabelle Lee Xin Yu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
| | - Andri K. Riau
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
| | - Jodhbir S. Mehta
- Cornea and External Eye Disease Service, Singapore National Eye Center, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (E.H.); (A.K.R.)
- Ophthalmology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore 169857, Singapore
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Malyugin BE, Belodedova A, Antonova O, Gelyastanov A, Tuuminen R, Levinger E, Achiron A, Knyazer B. Clinical comparison of manual and laser-cut corneal tunnel for intrastromal air injection in femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK). Graefes Arch Clin Exp Ophthalmol 2023; 261:185-191. [PMID: 35896678 DOI: 10.1007/s00417-022-05765-9] [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: 03/15/2022] [Revised: 06/30/2022] [Accepted: 07/09/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The most crucial step in deep anterior lamellar keratoplasty (DALK) is to achieve a bare Descemet's membrane. We aimed to assess a new femtosecond laser software that allows for a precise intrastromal tunnel creation for big bubble (BB) air injection using a real-time microscope-integrated optical coherence tomography. MATERIALS AND METHODS A retrospective review of 61 eyes of 61 patients with keratoconus. Before introducing the new software update, DALK was performed using a partial-assisted femtosecond laser (partial-thickness circular cut followed by a lamellar cut) with manual intrastromal tunnel creation (partial FS-DALK group). After the software update, the femtosecond laser created the intrastromal tunnel (full FS-DALK group). RESULTS In the full FS-DALK group, the BB's formation was significantly higher (64.3% vs. 36.4%, p = 0.04), and surgery time was shorter (21.8 ± 5.1 vs. 25.6 ± 6.8 min, p = 0.025) than in the partial FS-DALK. Penetrating keratoplasty conversion rate (7.1% vs. 15.1%, p = 0.432) was similar between the groups. Both groups showed statistically significant improvement in uncorrected and corrected distance visual acuity, central corneal thickness, surface asymmetry, and regularity indices. Endothelial cell density loss at 12 and 18 months was lower in the full compared with the partial FS-DALK group (12 months:10.0% vs. 16; 18 months: 10.7 vs. 16.5%, p < 0.001 for both comparisons). CONCLUSIONS Creating the intrastromal guiding tunnel using FS laser for air injection resulted in a higher rate of BB formation, reduced long-term endothelial cell loss, and operating room time.
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Affiliation(s)
- Boris E Malyugin
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation. .,A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation. .,Department of Ophthalmology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Alexandra Belodedova
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation
| | - Olga Antonova
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation
| | - Aslan Gelyastanov
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation
| | - Raimo Tuuminen
- Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.,Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland
| | - Eliya Levinger
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Dafna St 5, Tel Aviv-Yafo, Israel
| | - Asaf Achiron
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Dafna St 5, Tel Aviv-Yafo, Israel.
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Pedrotti E, Bonacci E, De Rossi A, Bonetto J, Chierego C, Fasolo A, De Gregorio A, Marchini G. Femtosecond Laser-Assisted Big-Bubble Deep Anterior Lamellar Keratoplasty. Clin Ophthalmol 2021; 15:645-650. [PMID: 33623365 PMCID: PMC7896764 DOI: 10.2147/opth.s294966] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/21/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To determine whether type 1 big-bubble (BB) formation is influenced by the sequence of incisions created with the Victus femtosecond laser (FSL) enabled with software version 3.4 (SV 3.4) during deep anterior lamellar keratoplasty (DALK). Materials and Methods Consecutive FSL-assisted DALK BB procedures were performed on 20 human donor corneas: 10 shaped by tunnel incision followed by lamellar incision (tunnel-lamellar group, TL) and 10 in the reverse order (lamellar-tunnel group, LT). The BB type was assessed by evaluating dynamic air movement during air inflation; bubble diameter and floor thickness were measured by anterior segment optical coherence tomography. Results Overall, a type 1 BB formed in 85% of eyes: 100% in the TL group and 70% in the LT group. In the LT group, a type 2 BB formed in 2 corneas and one cornea was perforated during cannula insertion. Type 1 BB was achieved after one attempt in 90% of eyes in the TL group and in 57% in the LT group. Conclusion Shaping the tunnel before rather than after lamellar incision may be more effective for obtaining a type 1 BB by air injection.
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Affiliation(s)
- Emilio Pedrotti
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy
| | - Erika Bonacci
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy
| | - Arianna De Rossi
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy
| | - Jacopo Bonetto
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy
| | - Chiara Chierego
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy
| | - Adriano Fasolo
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy.,Research Unit, The Veneto Eye Bank Foundation, Venezia, 30174, Italy
| | | | - Giorgio Marchini
- Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, 37134, Italy
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Li H, Chen M, Dong YL, Zhang J, Du XL, Cheng J, Gao H, Xie LX. Comparison of long-term results after manual and femtosecond assisted corneal trephination in deep anterior lamellar keratoplasty for keratoconus. Int J Ophthalmol 2020; 13:567-573. [PMID: 32399406 DOI: 10.18240/ijo.2020.04.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 12/07/2019] [Indexed: 11/23/2022] Open
Abstract
AIM To compare long-term postoperative outcomes of manual and femtosecond assisted corneal trephination in deep anterior lamellar keratoplasty (FS-DALK) for keratoconus. METHODS In the retrospective study, 17 consecutive eyes that underwent vertical side cut incision FS-DALK and 22 eyes that underwent trephine incision DALK were collected over a 2-year period. Main measurements included postoperative uncorrected-visual acuity (UCVA), corrected distance visual acuity (CDVA), refractive sphere and cylinder, manifest refraction spherical equivalent (MRSE), flat and steep corneal keratometry (K1 and K2), endothelial cell density (ECD), and time of epithelium healing and suture removal. RESULTS Groups were comparable for diagnosis and preoperative visual acuity. Follow-up averaged 23mo (range, 12-36mo). At 12mo, the mean UCVA was better in the manual-DALK group (P=0.039), and the refractive sphere was lower in the FS-DALK group (P=0.040). MRSE between groups differed at 1, 6, and 12mo postoperatively (P=0.047, 0.025, 0.042, respectively). Mean CDVA, cylinder, K1, K2, corneal astigmatism, ECD, and time of epithelium healing were similar between groups. Stability of MRSE, ECD, and K1 returned sooner after FS-DALK. Initial loosened suture removal time was earlier in the manual-DALK group (P=0.042) while complete suture removal time was similar (P=0.122). CONCLUSION Manual and femtosecond assisted corneal trephination in DALK are options for advanced keratoconus. FS-DALK do not result in improved visual acuity but it is more stable during the follow-up period. FS-DALK in the present form show limited benefit, so surgical design and parameters still need to be optimized and explored.
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Affiliation(s)
- Hua Li
- Department of Ophthalmology, Qilu Medical College of Shandong University, Jinan 250012, Shandong Province, China.,Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Min Chen
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Yan-Ling Dong
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Jing Zhang
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Xian-Li Du
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Jun Cheng
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Hua Gao
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Li-Xin Xie
- Qingdao Eye Hospital, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University&Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
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Buzzonetti L, Petrocelli G, Valente P, Petroni S, Parrilla R, Iarossi G. Refractive outcome of keratoconus treated by big-bubble deep anterior lamellar keratoplasty in pediatric patients: two-year follow-up comparison between mechanical trephine and femtosecond laser assisted techniques. EYE AND VISION 2019; 6:1. [PMID: 30656177 PMCID: PMC6330749 DOI: 10.1186/s40662-018-0127-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 12/22/2018] [Indexed: 11/24/2022]
Abstract
Background To evaluate refractive outcome 24 months after Deep Anterior Lamellar Keratoplasty (DALK) in pediatric patients by comparing results achieved using mechanical trephine and femtosecond laser. Methods Twenty eyes of 20 patients affected by keratoconus were evaluated. To perform big-bubble DALK, 10 eyes (Group 1; mean age 11.2 ± 2.2 years) were subjected to the Hessburg-Barron mechanical trephine and the remaining 10 eyes (Group 2; mean age 11.3 ± 3.1 years) to a 150 kHz femtosecond laser that performed mushroom incisions. Preoperative thinnest point in the corneal thickness map and K readings were measured by the Sirius Scheimpflug camera. We also evaluated corrected distance visual acuity (CDVA) as logMAR value using spectacles, spherical equivalent and refractive astigmatism. Results Mean preoperative thinnest point and pre- and post-operative K readings did not show significant difference (P > 0.05) between the two groups. CDVA, spherical equivalent and refractive astigmatism were respectively, 0.14 ± 0.08 logMAR and 0.13 ± 0.10 logMAR (P = 0.8), − 4.2 ± 1.1 D and − 2.8 ± 1.2 D (P = 0.03), 4.4 ± 2.0 D and 3.6 ± 1.2 D (P = 0.4) in Groups 1 and 2. All DALK procedures were uneventful. Conclusion Our findings suggest that femtosecond laser compared to mechanical trephine could significantly reduce the spherical equivalent amount in pediatric big-bubble DALK.
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Affiliation(s)
- Luca Buzzonetti
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Gianni Petrocelli
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Paola Valente
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Sergio Petroni
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Rosa Parrilla
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
| | - Giancarlo Iarossi
- Ophthalmology Department, Bambino Gesù IRCCS Children's Hospital, Via Torre di Palidoro snc - 00050 Passoscuro, Rome, Italy
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Abstract
Lamellar keratoplasty (LK) has revolutionized corneal graft surgery in several ways. Deep anterior LK (DALK) has eliminated risk of failure due to endothelial rejection. Endothelial keratoplasty (EK) has almost eliminated induced astigmatism and the “weak” graft–host junction as seen with penetrating keratoplasty (PK) and also reduced the risk of endothelial rejection. LK provided new insights into posterior corneal anatomy that led to better understanding and performance of DALK and to the development of another EK procedure, namely pre-Descemet's EK (PDEK). Surgical procedures for LK were further refined based on the improved understanding and are able to deliver better surgical outcomes in terms of structural integrity and long-term patient satisfaction, reducing the need of further surgeries and minimizing patient discomfort. In most specialist centers, anterior lamellar techniques like DALK and EK techniques like Descemet's stripping EK (DSEK) and Descemet's membrane EK (DMEK) have replaced the full-thickness PK where possible. The introduction of microkeratome, femtosecond laser, and PDEK clamp have made LK techniques easier and more predictable and have led to the innovation of another LK procedure, namely Bowman membrane transplant (BMT). In this article, we discuss the evolution of different surgical techniques, their principles, main outcomes, and limitations. To date, experience with BMT is limited, but DALK has become the gold standard for anterior LK. The EK procedures too have undergone a rapid transition from DSEK to DMEK and PDEK emerging as a viable option. Ultrathin-DSEK may still have a role in modern EK.
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Affiliation(s)
- Nadisha P Singh
- Division of Clinical Neuroscience, University of Nottingham, UK
| | - Dalia G Said
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust; Division of Clinical Neuroscience, University of Nottingham, UK
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Wang Z, Tan XJ, Zhai HL, Cheng J, Gao Y, Xie LX. Etiology and failure analysis of anterior lamellar keratoplasty. Int J Ophthalmol 2018; 11:786-790. [PMID: 29862176 DOI: 10.18240/ijo.2018.05.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 03/01/2018] [Indexed: 11/23/2022] Open
Abstract
AIM To analyze indications and reasons for failure of anterior lamellar keratoplasty (ALK). METHODS The clinical records were retrospectively reviewed. Main outcome measures included indications for ALK and reasons for failure of ALK. RESULTS A total of 434 patients (462 eyes) were treated with ALK at Qingdao Eye Hospital, Shandong Eye Institute from June 1, 2009 to May 31, 2016. The main indications were infectious keratitis (33.3%), keratoconus (23.6%), corneal dystrophy and degeneration (9.8%), Mooren's ulcer (8.4%), corneal neoplasm (7.8%), viral keratitis (6.5%) and regrafting (3.7%). Fungal keratitis accounted for 73.4% in the infectious keratitis cases. ALKs were failed in 36 patients, with the major causes being recurrence of primary diseases (63.9%). The leading causes of graft failure was Mooren's ulcer (36.1%), followed by infectious keratitis (30.6%). Recurrence of fungal keratitis accounted for 81.8% in the failed cases after ALK for infectious keratitis cases. CONCLUSION Infectious keratitis and keratoconus are the main indications for ALK, of which fungal keratitis was the major cause of corneal infections. Recurrence of primary disease is the main reason of graft failure after ALK, in which the main primary diseases associated with graft failure are Mooren's ulcer and fungal keratitis.
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Affiliation(s)
- Zhen Wang
- Qingdao University Medical College, Qingdao 266071, Shandong Province, China.,Affiliated Yidu Central Hospital of Weifang Medical College, Weifang 262500, Shandong Province, China
| | - Xiao-Jun Tan
- Affiliated Yidu Central Hospital of Weifang Medical College, Weifang 262500, Shandong Province, China
| | - Hua-Lei Zhai
- Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Jun Cheng
- Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Yan Gao
- Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Li-Xin Xie
- Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
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[Comparison of anatomic and functional results between Z6 femtosecond laser assisted and manual trephination in deep anterior lamellar keratoplasty for advanced keratoconus [French version]]. J Fr Ophtalmol 2017; 40:571-579. [PMID: 28844326 DOI: 10.1016/j.jfo.2017.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 01/22/2017] [Accepted: 01/24/2017] [Indexed: 11/20/2022]
Abstract
The management of severe keratoconus requires corneal transplantation, for which the gold standard is deep anterior lamellar keratoplasty (DALK), preserving the healthy Descemet's membrane and endothelium. The safety and reproducibility of corneal cuts have been improved by the evolution of femtosecond lasers in refractive surgery, and femtosecond laser in DALK would seem to provide the same advantages over the manual method. In our retrospective study, we compare functional and anatomical results of femtosecond assisted DALK versus manual trephination DALK in patients with keratoconus in stage 4 of the Krumeich classification. It is a retrospective study including all patients with stage 4 keratoconus who underwent femtosecond laser assisted DALK between November 2012 and November 2015 in Nantes hospital. We compared those patients to a group of patients who underwent manual DALK in the same period, paired by age and maximal keratometry. We assessed visual acuity, pachymetry, endothelial cell density (specular microscopy), and keratometry before surgery and at 4, 8 and 12 months of follow-up. Laser settings and intraoperative complications were recorded. Nineteen patients underwent surgery by femtosecond assisted DALK, 6 women and 12 men with average age 30.2±10.8 years at transplantation. They were paired with a group of 17 patients who underwent manual DALK in order to compare results. Before surgery, mean visual acuity in the femtosecond group was 0.90 logMAR versus 0.89 logMAR in the manual group, showing no statistically significant difference (P=0.96). Both groups were similar in terms of preoperative age, mean keratometry, pachymetry and endothelial cell density. Average visual acuity post-surgery was 0.27, 0.26; and 0.14 logMAR for femtosecond DALK versus 0.27, 0.17 et 0.25 for manual DALK at 4, 8 and 12 months follow-up, respectively showing no statistically significant difference. After surgery, at 4, 8 and 12 months, mean pachymetry was similar in both groups, and average endothelial cell density was 2390 cells/mm2 in femtoDALK versus 2531 cells/mm2 in manual DALK at 12 months of follow-up, showing no statistically significant difference (P=0.5726). The rate of Descemet's membrane microperforations during the procedure was low and similar for both groups. Our study allows for a 12 month follow-up, with assessment of visual recovery, anatomical result and endothelial safety in a sample of 19 femtosecond laser assisted DALK with no statistical significant difference versus the manual trephination group. Femtosecond laser allows for increased reproducibility of the DALK procedure without reducing adverse effects during surgery. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. A medical economics study would be necessary to determine the cost effectiveness of femtosecond laser assisted DALK.
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Lu Y, Chen X, Yang L, Xue C, Huang Z. Femtosecond laser-assisted deep anterior lamellar keratoplasty with big-bubble technique for keratoconus. Indian J Ophthalmol 2017; 64:639-642. [PMID: 27853010 PMCID: PMC5151152 DOI: 10.4103/0301-4738.194326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose: The purpose of this study was to evaluate the clinical results after deep anterior lamellar keratoplasty (DALK) assisted by the femtosecond laser with big-bubble technique for keratoconus. Methods: A case series of 22 eyes in 19 patients with keratoconus was enrolled in the study. The 500-kHz VisuMax femtosecond laser (Carl Zeiss Meditec AG, Jena, Germany) was used to create a vertical side cut on donor and recipient corneas. Intraoperative and postoperative complications, uncorrected visual acuity, best-corrected visual acuity, corneal curvature, and central corneal thickness were evaluated in all patients. Results: Big-bubble and naked Descemet's membrane (DM) were successfully achieved in twenty eyes (90.9%). Intraoperative macroperforation of DM occurred in two cases and converted to full-thickness keratoplasty. The mean follow-up time was 18.8 ± 5.3 months. The best-corrected visual acuity was increased from 0.3 to 1.0, mean corneal curvature was 43.0 ± 2.3D, and mean central corneal thickness was 508.9 ± 60.1 μm (range, from 430 to 600 μm) postoperatively. Conclusion: Our results indicate that femtosecond laser-assisted DALK with big-bubble technique is an accurate, safe, and effective method to treat the patients with keratoconus.
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Affiliation(s)
- Yan Lu
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Xiangfei Chen
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University; Department of Endocrinology, Geriatric Research Center, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Liping Yang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Chunyan Xue
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Zhenping Huang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
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Blériot A, Martin E, Lebranchu P, Zimmerman K, Libeau L, Weber M, Vabres B, Orignac I. Comparison of 12-month anatomic and functional results between Z6 femtosecond laser-assisted and manual trephination in deep anterior lamellar keratoplasty for advanced keratoconus. J Fr Ophtalmol 2017; 40:e193-e200. [PMID: 28601345 DOI: 10.1016/j.jfo.2017.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 04/23/2017] [Accepted: 05/02/2017] [Indexed: 11/19/2022]
Abstract
The management of severe keratoconus requires corneal transplantation, for which the gold standard is deep anterior lamellar keratoplasty (DALK), preserving the healthy Descemet's membrane and endothelium. The safety and reproducibility of corneal cuts have been improved by the evolution of femtosecond lasers in refractive surgery, and femtosecond laser in DALK would seem to provide the same advantages over the manual method. In our retrospective study, we compare functional and anatomical results of femtosecond-assisted DALK versus manual trephination DALK in patients with keratoconus in stage 4 of the Krumeich classification. It is a retrospective study including all patients with stage 4 keratoconus who underwent femtosecond laser-assisted DALK between November 2012 and November 2015 in Nantes university medical center. We compared those patients to a group of patients who underwent manual DALK in the same period, paired by age and maximal keratometry. We assessed visual acuity, pachymetry, endothelial cell density (specular microscopy), and keratometry before surgery and at 4, 8 and 12 months of follow-up. Laser settings and intraoperative complications were recorded. Nineteen patients underwent surgery by femtosecond-assisted DALK, 6 women and 12 men with average age 30.2±10.8 years at transplantation. They were paired with a group of 17 patients who underwent manual DALK in order to compare results. Before surgery, mean visual acuity in the femtosecond group was 0.90 logMAR versus 0.89 logMAR in the manual group, showing no statistically significant difference (P=0.96). Both groups were similar in terms of preoperative age, mean keratometry, pachymetry and endothelial cell density. Average visual acuity post-surgery was 0.27; 0.26; and 0.14 logMAR for femtosecond DALK versus 0.27; 0.17 et 0.25 for manual DALK at 4, 8 and 12 months follow-up respectively, showing no statistically significant difference. After surgery, at 4, 8 and 12 months, mean pachymetry was similar in both groups, and average endothelial cell density was 2390 cells/mm2 for femto DALK versus 2531 cells/mm2 for manual DALK at 12 months of follow-up, showing no statistically significant difference (P=0.5726). The rate of Descemet's membrane microperforations during the procedure was low and similar for both groups. Our study allows for a 12-month follow-up, with assessment of visual recovery, anatomic result and endothelial safety in a series of 19 femtosecond laser-assisted DALK with no statistical significant difference versus the manual trephination group. Femtosecond laser allows for increased reproducibility of the DALK procedure without reducing adverse effects during surgery. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. A medical economics study would be necessary to determine the cost-effectiveness of femtosecond laser-assisted DALK.
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Affiliation(s)
- A Blériot
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - E Martin
- Ophthalmology service, Saint-Nazaire medical center, cité sanitaire Georges-Charpak, 11, boulevard Georges-Charpak, BP 414, 44606 Saint-Nazaire, France
| | - P Lebranchu
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - K Zimmerman
- MEDICARE-HTM, 3, rue Alain-Bombard, 44800 Saint-Herblain, France
| | - L Libeau
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Weber
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - B Vabres
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - I Orignac
- Ophthalmology service, Nantes university medical center, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Abstract
In recent years, there has been a considerable interest regarding the concept of lamellar keratoplasty (LK), which contributed in spreading the use of this procedure in the treatment of keratoconus. This is a new frontier in corneal surgery that minimizes trauma on the recipient patient since it works on a "closed bulb". The LK surgery, in fact, aims to selectively replace diseased corneal stroma, leaving the healthy endothelium. The main advantage of LK is to avoid major causes of failure of penetrating keratoplasty as immunological rejection, and the late mismatch in the transplanted cornea, thus increasing the life of transplantation. In the last decade, several techniques of LK have been proposed, depending on how the anterior portion of the recipient cornea is removed. This article, through a literary research reviews the various emerging techniques of anterior lamellar surgery for the management of keratoconus, analyzing their indications, visual outcomes, and rate of complications.
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Affiliation(s)
- Leopoldo Spadea
- Department of Biotechnology and Medical Surgical Sciences, Sapienza University of Rome, Latina, Italy. E-mail.
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Zhang C, Liu L, Tang M, Li Y, Chamberlain W, Huang D. Laboratory Evaluation of Femtosecond Laser Lamellar Cuts in Gamma-Irradiated Corneas. Cornea 2016; 34:1499-503. [PMID: 26382890 DOI: 10.1097/ico.0000000000000614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the stromal interface quality after femtosecond laser full lamellar cuts in gamma-irradiated corneas (VisionGraft sterile cornea) and to determine the limits of the cut depth using the VisionGraft as donor corneas for laser-assisted lamellar anterior keratoplasty. METHODS Fourteen VisionGraft corneas underwent full lamellar cuts using the femtosecond laser. The percent cut depth was 17% to 21% (100 μm, n = 2), 31% to 35% (n = 3), 38% to 40% (n = 3), 45% to 48% (n = 3), and 50% (n = 3) of the total stromal thickness (not including the epithelium). The cap and stromal bed surfaces were imaged with a scanning electron microscope. The quality of cut surfaces was graded by 2 masked observers based on two indices: ridge and roughness. Ridge grading indicated macroscopic irregularity. Roughness grading indicated microscopic irregularity. The grading was done on a subjective integer scale of 1 to 5 (1 = best and 5 = worst), which was used in a previous study of cut quality in fresh corneas. RESULTS The ridge grading ranged from 1.5 for the shallowest cut to 2.2 for the deepest cut and weakly (r = 0.279) but significantly (P = 0.037) correlated with the percent cut depth. The roughness grading ranged from 2.63 to 2.56 and showed no trend with the percent cut depth (r = 0.006, P = 0.968). CONCLUSIONS Compared with previously published results of fresh corneas, in which ridge grading exceeded 3 for cuts deeper than 31%, cut quality was better for the VisionGraft. Even at depths up to 48% of the total stromal thickness, ridge grading was not worse than shallow cuts. Thus, gamma-irradiated corneas could provide a smoother interface than do fresh eye bank corneas for laser-assisted lamellar anterior keratoplasty.
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Affiliation(s)
- Chenxing Zhang
- *Center for Ophthalmic Optics and Lasers, Casey Eye Institute, Portland, OR; †Department of Ophthalmology, Oregon Health and Science University, Portland, OR; ‡Department of Ophthalmology, Southwest Eye Hospital, Third Military Medical University, Chongqing, China; and §Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, China
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Buzzonetti L, Petrocelli G, Valente P, Iarossi G, Ardia R, Petroni S, Parrilla R. The Big-Bubble Full Femtosecond Laser-Assisted Technique in Deep Anterior Lamellar Keratoplasty. J Refract Surg 2015; 31:830-4. [DOI: 10.3928/1081597x-20151111-07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/08/2015] [Indexed: 11/20/2022]
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Chen Y, Hu DN, Xia Y, Yang L, Xue C, Huang Z. Comparison of femtosecond laser-assisted deep anterior lamellar keratoplasty and penetrating keratoplasty for keratoconus. BMC Ophthalmol 2015; 15:144. [PMID: 26507262 PMCID: PMC4624596 DOI: 10.1186/s12886-015-0140-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare outcomes of femtosecond laser-assisted deep anterior lamellar keratoplasty (FSL-DALK) and penetrating keratoplasty (FSL-PK) for the treatment of keratoconus. METHODS Twenty eight eyes underwent FSL-DALK (consisted of 12 eyes in the FSL-DALKa subgroup without baring the Descemet's membrane and 16 eyes in the FSL-DALKb subgroup baring the Descemet's membrane using big-bubble technique) were compared with 12 eyes that underwent FSL-PK for keratoconus. These patients underwent an ophthalmic examination preoperatively and 3, 6, 9, and 12 months postoperatively. RESULTS The postoperative BCVA in the FSL-PK group, and the FSL-DALKb subgroup were significantly better than that in the FSL-DALKa subgroup (P < 0.05), whereas no differences were found between the FSL-DALKb subgroup and the FSL-PK group (P > 0.05). There were no significant differences in the mean spherical equivalent (SE) and astigmatism between the FSL-DALK and the FSL-PK groups, nor between the subgroups of FSL-DALK during the follow-up period (P > 0.05). At the last follow-up, the mean endothelial cell loss in the FSL-DALK group (9.12 %) was significantly less than that in the FSL-PK group (20.79 %) (P < 0.001), while there was no difference between the FSL-DALKa (9.15 %) and the FSL-DALKb (9.10 %) subgroups (P = 0.15). The FSL-DALK group seemed to have fewer graft rejections (1/28 cases) than the FSL-PK group (2/12 cases), although Kaplan-Meier curve showed no significant difference between the two groups (P = 0.144). CONCLUSIONS In this retrospective study, the results suggested that FSL-DALKb gives better visual outcome, and FSL-DALKb is a better option for keratoconus whose endothelium is not compromised. However, larger and prospective studies are further required.
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Affiliation(s)
- Yueqin Chen
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China. .,Tissue Culture Center, Departments of Pathology and Ophthalmology, The New York Eye and Ear Infirmary, New York Medical College, New York, NY, 10003, USA.
| | - Dan-Ning Hu
- Tissue Culture Center, Departments of Pathology and Ophthalmology, The New York Eye and Ear Infirmary, New York Medical College, New York, NY, 10003, USA.
| | - Yuan Xia
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China.
| | - Liping Yang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China.
| | - Chunyan Xue
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China.
| | - Zhenping Huang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China.
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Aristeidou A, Taniguchi EV, Tsatsos M, Muller R, McAlinden C, Pineda R, Paschalis EI. The evolution of corneal and refractive surgery with the femtosecond laser. EYE AND VISION 2015; 2:12. [PMID: 26605365 PMCID: PMC4655461 DOI: 10.1186/s40662-015-0022-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/20/2015] [Indexed: 01/12/2023]
Abstract
The use of femtosecond lasers has created an evolution in modern corneal and refractive surgery. With accuracy, safety, and repeatability, eye surgeons can utilize the femtosecond laser in almost all anterior refractive procedures; laser in situ keratomileusis (LASIK), small incision lenticule extraction (SMILE), penetrating keratoplasty (PKP), insertion of intracorneal ring segments, anterior and posterior lamellar keratoplasty (Deep anterior lamellar keratoplasty (DALK) and Descemet's stripping endothelial keratoplasty (DSEK)), insertion of corneal inlays and cataract surgery. As the technology matures, it will push surgical limits and open new avenues for ophthalmic intervention in areas not yet explored. As we witness the transition from femto-LASIK to femto-cataract surgery it becomes obvious that this innovation is here to stay. This article presents some of the most relevant advances of femtosecond lasers to modern corneal and refractive surgery.
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Affiliation(s)
| | - Elise V Taniguchi
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA USA ; Massachusetts Eye and Ear Infirmary/Schepens Eye Research Institute, Boston Keratoprosthesis Laboratory, Harvard Medical School, Boston, 02114 MA USA
| | | | - Rodrigo Muller
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA USA
| | - Colm McAlinden
- Flinders University, Adelaide, South Australia Australia ; Wenzhou Medical University, Wenzhou, Zhejiang China
| | - Roberto Pineda
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA USA
| | - Eleftherios I Paschalis
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA USA ; Massachusetts Eye and Ear Infirmary/Schepens Eye Research Institute, Boston Keratoprosthesis Laboratory, Harvard Medical School, Boston, 02114 MA USA
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Zhang C, Bald M, Tang M, Li Y, Huang D. Interface quality of different corneal lamellar-cut depths for femtosecond laser-assisted lamellar anterior keratoplasty. J Cataract Refract Surg 2015; 41:827-35. [PMID: 25747165 DOI: 10.1016/j.jcrs.2014.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 07/31/2014] [Accepted: 08/19/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the interface quality of different corneal lamellar-cut depths with the femtosecond laser and determine a feasible range of depth for femtosecond laser-assisted lamellar anterior keratoplasty. SETTING Casey Eye Institute, Portland, Oregon, USA. DESIGN Experimental study. METHODS Full lamellar cuts were made on 20 deepithelialized human cadaver corneas using the femtosecond laser. The cut depth was 17% to 21% (100 μm), 31%, 35%, 38% to 40%, and 45% to 48% of the central stromal thickness. Scanning electron microscopy images of the cap and bed surfaces were subjectively graded for ridge and roughness using a scale of 1 to 5 (1 = best). The graft-host match was evaluated by photography and optical coherence tomography in a simulated procedure. RESULTS The ridge score was correlated with the cut depth (P = .0078, R = 0.58) and better correlated with the percentage cut depth (P = .00024, R = 0.73). The shallowest cuts had the fewest ridges (score 1.25). The 31% cut depth produced significantly fewer ridges (score 2.15) than deeper cuts. The roughness score ranged from 2.19 to 3.08 for various depths. A simulated procedure using a 100 μm host cut and a 177 μm (31%) graft had a smooth interface and flush anterior junction using an inverted side-cut design. CONCLUSIONS The femtosecond laser produced more ridges in deeper lamellar cuts. A depth setting of 31% stromal thickness might produce adequate surface quality for femtosecond laser-assisted lamellar anterior keratoplasty. The inverted side-cut design produced good edge apposition even when the graft was thicker than the host lamellar-cut depth. FINANCIAL DISCLOSURE Proprietary or commercial disclosures are listed after the references.
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Affiliation(s)
- Chenxing Zhang
- From the Center for Ophthalmic Optics & Lasers (Zhang, Bald, Tang, Li, Huang), Casey Eye Institute and Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon, USA; the Southwest Eye Hospital (Zhang), Third Military Medical University, Chongqing, China
| | - Matthew Bald
- From the Center for Ophthalmic Optics & Lasers (Zhang, Bald, Tang, Li, Huang), Casey Eye Institute and Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon, USA; the Southwest Eye Hospital (Zhang), Third Military Medical University, Chongqing, China
| | - Maolong Tang
- From the Center for Ophthalmic Optics & Lasers (Zhang, Bald, Tang, Li, Huang), Casey Eye Institute and Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon, USA; the Southwest Eye Hospital (Zhang), Third Military Medical University, Chongqing, China
| | - Yan Li
- From the Center for Ophthalmic Optics & Lasers (Zhang, Bald, Tang, Li, Huang), Casey Eye Institute and Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon, USA; the Southwest Eye Hospital (Zhang), Third Military Medical University, Chongqing, China
| | - David Huang
- From the Center for Ophthalmic Optics & Lasers (Zhang, Bald, Tang, Li, Huang), Casey Eye Institute and Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon, USA; the Southwest Eye Hospital (Zhang), Third Military Medical University, Chongqing, China.
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Moshirfar M, Edmonds JN, Behunin NL, Christiansen SM. Current Options in the Management of Pellucid Marginal Degeneration. J Refract Surg 2014; 30:474-85. [DOI: 10.3928/1081597x-20140429-02] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/11/2014] [Indexed: 11/20/2022]
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Big bubble deep anterior lamellar keratoplasty for management of deep fungal keratitis. J Ophthalmol 2014; 2014:209759. [PMID: 25105019 PMCID: PMC4106058 DOI: 10.1155/2014/209759] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/17/2014] [Indexed: 11/17/2022] Open
Abstract
Objective. To evaluate the therapeutic effect of big bubble deep anterior lamellar keratoplasty (DALK) in patients with deep fungal keratitis. Methods.Consecutive patients who had DALK for deep fungal keratitis at Shandong Eye Hospital between July 2011 and December 2012 were included. In all patients, the infiltration depth was more than 4/5ths of the corneal thickness. DALK surgery was performed with bare Descemet membrane (DM) using the big bubble technique. Corrected distance visual acuity (CDVA), graft status, and intraoperative and postoperative complications were monitored. Results. Big bubble DALK was performed in 23 patients (23 eyes). Intraoperative perforation of the DM occurred in two eyes (8.7%) during stromal dissection. The patients received lamellar keratoplasty with an air bubble injected into the anterior chamber. Double anterior chamber formed in 3 eyes (13.0%). Mean CDVA of the patients without cataract, amblyopia, and fungal recurrence was improved from preoperative HM/20 cm−1.0 (LogMAR) to 0.23 ± 0.13 (LogMAR) at the last followup (P < 0.01). Fungal recurrence was found in two patients (8.7%). Corneal stromal graft rejection was noted in one patient (4.3%). Conclusions. DALK using the big bubble technique seems to be effective and safe in the treatment of deep fungal keratitis unresponsive to medication.
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Rajan MS. Surgical strategies to improve visual outcomes in corneal transplantation. Eye (Lond) 2014; 28:196-201. [PMID: 24384964 DOI: 10.1038/eye.2013.279] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 11/21/2013] [Indexed: 11/09/2022] Open
Abstract
The recent years have brought about a sea change in the field of corneal transplantation with penetrating keratoplasty being phased to newer lamellar keratoplasty techniques for a variety of corneal pathology. Improved and innovative surgical techniques have allowed selective replacement of diseased host corneal layers with pre-prepared healthy donor corneal lamellae for anterior corneal disorders such as keratoconus and posterior corneal disorders such as Fuch's corneal endothelial dystrophy. The results of lamellar techniques are encouraging, with rapid visual rehabilitation and vastly reduced risk of immune-mediated transplant rejection. The techniques of deep anterior lamellar keratoplasty and Descemet's stripping endothelial keratoplasty (DSAEK) continue to evolve with advent of femtosecond lasers and newer concepts such as pre-conditioned donor corneas for Microthin DSAEK and Descemet's membrane keratoplasty. This review describes the current developments in lamellar keratoplasty, including the futuristic approach using cell therapy to restore vision in corneal blindness.
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Affiliation(s)
- M S Rajan
- 1] Cornea Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK [2] Vision and Eye Research Unit (VERU), Anglia Ruskin University, Cambridge, UK
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Deep anterior lamellar keratoplasty: surgical techniques, challenges, and management of intraoperative complications. Int Ophthalmol Clin 2013; 53:47-58. [PMID: 23470588 DOI: 10.1097/iio.0b013e31827eb746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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