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Moramarco A, Gardini L, Di Mola I, di Geronimo N, Iannetta D, Romano V, Hannush SB, Fontana L. Big-bubble DALK: A technique in evolution. Ocul Surf 2024; 34:418-429. [PMID: 39369903 DOI: 10.1016/j.jtos.2024.10.001] [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: 06/24/2024] [Revised: 09/29/2024] [Accepted: 10/01/2024] [Indexed: 10/08/2024]
Abstract
Deep anterior lamellar keratoplasty (DALK) is considered a valuablealternative to penetrating keratoplasty (PK) for treatingcorneal disordersthat do not involve theendothelium. DALK preserves the host endothelium, eliminating the risk of endothelial rejection and reducing the risk of late graft failure due to endothelial decay. Despite its not recent introduction, DALK has been considered a difficult, lengthy, and poorly reproducible procedure, limiting its adoption worldwide. With the introduction of the big-bubble technique (BBT) the reproducibility and the time required to complete the procedure were significantly improved, encouraging many surgeons to approach DALK. With BBT air is injected into the stroma to induce separation between the layers of the cornea, facilitating the separation of the diseased or scarred stroma from the healthy endothelium; this allows the creation of a graft-host interface of pristine optical quality, granting clinical results equal to those obtained with PK.Understanding the anatomy and physics behind the big bubble (BB) formation is crucial for thesurgical success of this technique. The discovery of the pre-Descemet's layer (Dua's layer)played a significant role in understanding the principles behindBBformation, considerablyimpacting the safety and reproducibility of the technique. BB formation is influenced by preoperative pathology, trephination size, and instruments used for air injection.Continue advancements have helped to refine BBT's efficacy and reproducibility, broadening its applicability in corneal transplantation whenever the endothelium is healthy.This review provides a detailed account of the procedural steps involved in DALK using the BBT, addressing the most common challenges, highlightingtechnical innovations, and handlingthe most frequent complications.
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Affiliation(s)
| | - Lorenzo Gardini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater StudiorumUniversity of Bologna, Bologna, Italy
| | - Ilaria Di Mola
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater StudiorumUniversity of Bologna, Bologna, Italy
| | - Natalie di Geronimo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater StudiorumUniversity of Bologna, Bologna, Italy
| | - Danilo Iannetta
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; University of Rome La Sapienza, Department of Organs of Sense, Rome, Italy
| | - Vito Romano
- Eye Unit, ASST Spedali Civili di Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy; Eye Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Viale Europa 15, 25123, Brescia, Italy
| | - Sadeer B Hannush
- Cornea Service, Wills Eye Hospital, Philadelphia, PA. USA; Ophthalmology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Luigi Fontana
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater StudiorumUniversity of Bologna, Bologna, Italy.
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Aiello F, Pocobelli G, Iovieno A, Komaiha C, Nucci C, Pocobelli A. Clinical Outcomes of Modified Manual Deep Anterior Lamellar Keratoplasty for Eyes with Previous Radial Keratotomy. J Clin Med 2024; 13:5250. [PMID: 39274462 PMCID: PMC11395999 DOI: 10.3390/jcm13175250] [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: 07/29/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/16/2024] Open
Abstract
Background: The aim of this study was to evaluate the intraoperative complications and visual outcomes of manual deep anterior lamellar keratoplasty (mDALK) in patients who underwent previous radial keratotomy (RK) for myopia. Methods: The notes of patients who underwent mDALK after RK at three different hospitals-San Giovanni Addolorata Hospital (Rome, Italy), Mount Saint Joseph Hospital (Vancouver, Canada), and Tor Vergata University Hospital (Rome, Italy)-were retrospectively reviewed. We analyzed the manual dissection success rate and conversion to penetrating keratoplasty (PK), the residual recipient stromal thickness, the postoperative corrected distance visual acuity (CDVA), postoperative refraction, and topographic astigmatism. Results: Thirteen eyes of eleven patients were included in the analysis (male 7/11, 63.6%). Preoperatively, mean topographic astigmatism was 5.4 ± 3.5 D (range 1.6-14.8 D), and mean CDVA was 0.47 ± 0.2 logMAR (range 0.3-1.0 logMAR) [Snellen equivalent 20/50]. Manual dissection was performed in all cases. None of the examined eyes were converted to PK. An improvement in both topographic astigmatism (2.8 ± 0.9 D, p = 0.0135) and CDVA (0.23 ± 0.2 LogMAR, p = 0.0122) was recorded at 12-month follow-up. Conclusions: mDALK is a safe and effective surgical technique when applied to eyes previously treated with RK, with an observed improvement in CDVA and topographic astigmatism.
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Affiliation(s)
- Francesco Aiello
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Giulio Pocobelli
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", 00133 Rome, Italy
- Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, UK
| | - Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC V5Z 3N9, Canada
- Providence Health Care, Vancouver, BC V5Z 3N9, Canada
| | - Chiara Komaiha
- Ophthalmology Unit-Eye Bank of Rome, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Carlo Nucci
- Ophthalmology Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Augusto Pocobelli
- Ophthalmology Unit-Eye Bank of Rome, San Giovanni Addolorata Hospital, 00184 Rome, Italy
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Lucchino L, Visioli G, Scarinci F, Colabelli Gisoldi RAM, Komaiha C, Marenco M, Pocobelli G, Lambiase A, Pocobelli A. Tomographic and topographic predictive factors of big bubble formation during deep anterior lamellar keratoplasty in keratoconus. Br J Ophthalmol 2024:bjo-2024-325810. [PMID: 39197954 DOI: 10.1136/bjo-2024-325810] [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: 05/17/2024] [Accepted: 08/13/2024] [Indexed: 09/01/2024]
Abstract
PURPOSE To identify preoperative predictors of big bubble (BB) formation during deep anterior lamellar keratoplasty (DALK) in patients with keratoconus (KC). METHODS DESIGN: Retrospective cohort study in an Italian tertiary centre. STUDY POPULATION Consecutive patients with KC undergoing DALK from January 2021 to July 2023. OBSERVATION PROCEDURE Tomographic and topographic data including K-max, K-mean, keratometric astigmatism, thinnest point, mean peripheral corneal thickness, difference between the mean peripheral corneal thickness and the thinnest point (peripheral-minimal corneal thickness), position (central/paracentral) and cone area (%), Amsler-Krumeich classification and anterior segment optical coherence tomography (AS-OCT) analysis to assess the severity stage. MAIN OUTCOME MEASURES Rate of BB formation and type; multivariate logistic regression analysis was used to analyse all preoperative parameters in patients with BB formation versus failure. RESULTS Pneumatic dissection succeeded in 98 of 140 eyes (70.0%), with 94 type 1 bubbles (67.1%) and four type 2 bubbles (2.9%). BB formation succeeded more frequently in patients with lower K-max (p=0.032), lower K-mean (p=0.010), higher thinnest point (p=0.017), lower peripheral-minimal corneal thickness (p=0.009) and lower Amsler-Krumeich stages (p=0.021). According to the AS-OCT analysis, BB formation was more frequent in the lower stages (p<0.001). After the logistic regression (pseudo-R²=0.176, constant=3.21, 95% CI 1.14 to 5.29, p=0.002), AS-OCT classification was found to be the only factor that predicted BB formation (coefficient=-0.81, 95% CI -1.18 to -0.43, p<0.001). CONCLUSIONS AS-OCT classification is a reliable predictor for BB formation. Tomographic and topographic analyses indicated that a steeper and more ectatic cornea is more prone to BB failure.
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Affiliation(s)
- Luca Lucchino
- Department of Sense Organs, Sapienza - University of Rome, Rome, Italy
| | - Giacomo Visioli
- Department of Sense Organs, Sapienza - University of Rome, Rome, Italy
| | - Fabio Scarinci
- UOC Oftalmologia - Banca degli Occhi, San Giovanni Addolorata Hospital, Rome, Italy
| | | | - Chiara Komaiha
- UOC Oftalmologia - Banca degli Occhi, San Giovanni Addolorata Hospital, Rome, Italy
| | - Marco Marenco
- Department of Sense Organs, Sapienza - University of Rome, Rome, Italy
| | - Giulio Pocobelli
- Department of Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | | | - Augusto Pocobelli
- UOC Oftalmologia - Banca degli Occhi, San Giovanni Addolorata Hospital, Rome, Italy
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Elalfy M, Negm A, Soliman S, Naveed H, Hamada S, Matsou A, Hassan M, Atef A, Gatzioufas Z, Mahran W. Surgical Outcomes of Different Deep Anterior Lamellar Keratoplasty Techniques-A Single-Centre UK Study. J Clin Med 2024; 13:3644. [PMID: 38999210 PMCID: PMC11242575 DOI: 10.3390/jcm13133644] [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: 03/20/2024] [Revised: 06/16/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Anterior lamellar keratoplasty (ALK) is a less invasive procedure than PK, and thus avoids many of the intraocular complications associated with PK. DALK can be performed using several different techniques, with either a manual dissection, a keratome or femtosecond-laser assisted dissection, or with a big bubble technique. To analyse the outcomes and compare the results of three deep anterior lamellar keratoplasty (DALK) techniques. Methods: This study included 105 DALK cases performed at Queen Victoria Hospital, East Grinstead, UK, in the period between January 2016 and May 2022. Cases were classified into four groups based on technique: BB-DALK, manual DALK, FS-DALK and 'converted to PK group'. Results: There was significant improvement in VA and Kmax compared to the preoperative values in all groups. There was no significant difference detected in VA and Kmax between all groups. Conclusions: Performing DALK surgery with any suitable technique (manual, big-bubble or femtosecond-assisted) is effective and causes significant improvements in VA and Kmax, even in cases where a conversion to penetrating keratoplasty is required. However, every technique has its pros and cons and should be tailored according to surgeon preference and individual case pathology.
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Affiliation(s)
- Mohamed Elalfy
- Queen Victoria Hospital Foundation Trust, East Grinstead RH19 3DZ, UK
- Maidstone and Tunbridge Wells NHS Trust, Maidstone TN24QJ, UK
- Research Institute of Ophthalmology, Giza 3724827, Egypt
| | - Ahmed Negm
- Research Institute of Ophthalmology, Giza 3724827, Egypt
| | - Shady Soliman
- Research Institute of Ophthalmology, Giza 3724827, Egypt
| | - Hasan Naveed
- Queen Victoria Hospital Foundation Trust, East Grinstead RH19 3DZ, UK
| | - Samer Hamada
- Queen Victoria Hospital Foundation Trust, East Grinstead RH19 3DZ, UK
| | - Artemis Matsou
- Queen Victoria Hospital Foundation Trust, East Grinstead RH19 3DZ, UK
| | - Mansour Hassan
- Department of Ophthalmology, Faculty of Medicine, Beni Suef University, Beni Suef 62514, Egypt
| | - Ahmed Atef
- Research Institute of Ophthalmology, Giza 3724827, Egypt
| | - Zisis Gatzioufas
- Department of Ophthalmology, University Hospital Basel, 4031 Basel, Switzerland
| | - Waleed Mahran
- Department of Ophthalmology, Faculty of Medicine, Beni Suef University, Beni Suef 62514, Egypt
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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.
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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
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Berger T, Seitz B, Hamon L, Flockerzi F, Schlötzer-Schrehardt U, Daas L. Ultrastructural Examination of the Corneal Interface after Predescemetic Deep Anterior Lamellar Keratoplasty (DALK) - A Case Report with Light and Transmission Electron Microscopy. Klin Monbl Augenheilkd 2023; 240:1010-1016. [PMID: 35320861 DOI: 10.1055/a-1745-9140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To examine corneal buttons with light and transmission electron microscopy (TEM) to visualize the interface area and highlight the ultrastructural corneal changes after deep anterior lamellar keratoplasty (DALK). METHODS Two patients underwent excimer laser-assisted penetrating repeat keratoplasty after predescemetic DALK. The corneal buttons were examined by light microscopy and TEM. RESULTS The light microscopic examination of the corneal buttons revealed fragments of a second Descemet's membrane in the central and midperipheral areas (Case 1). In both cases, visualization of the interface area was not possible by light microscopy. The donor and host stroma were tightly attached without dehiscence. TEM identified the interface area by irregularities in the collagen distribution between the donor and host stroma. The thickness of the remaining recipient corneal stroma measured approximately 30 µm (Case 1) and 100 µm (Case 2), respectively. In the host stroma, TEM revealed the absence or degeneration of keratocytes, accumulation of amorphous material between the collagen lamellae, and vacuolar inclusions dispersed in the stroma, forming a band-like zone anterior to Descemet's membrane. CONCLUSION The interface area after DALK has been mainly investigated by in vivo confocal microscopy. Light microscopy and TEM findings indicate remodeling processes after DALK that are associated with increased keratocyte degeneration and structural alterations of the extracellular matrix in the host stroma. The choice of surgical method may influence the postoperative morphological and functional outcome since these findings were primarily apparent in the remaining host stroma. Therefore, complete exposure of Descemet's membrane is an important prognostic factor for the postoperative visual outcome.
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Affiliation(s)
- Tim Berger
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Germany
| | - Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Germany
| | - Loïc Hamon
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Germany
| | - Fidelis Flockerzi
- Institut für Allgemeine und Spezielle Pathologie, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Germany
| | | | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Germany
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Alfonso-Bartolozzi B, Lisa C, Fernández-Vega-Cueto L, Madrid-Costa D, Alfonso JF. A New Pre-descemetic Corneal Ring (Neoring) in Deep Anterior Lamellar Keratoplasty for Moderate-Advanced Keratoconus: A Pilot 2-Year Long-Term Follow-Up Study. Front Med (Lausanne) 2021; 8:771365. [PMID: 34805231 PMCID: PMC8599962 DOI: 10.3389/fmed.2021.771365] [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: 09/06/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose: To assess the outcomes of implanting a new polymethylmethacrylate (PMMA) ring (Neoring; AJL Ophthalmic) in pre-descemet deep anterior lamellar keratoplasty (PD-DALK) procedure for moderate-advanced keratoconus. Methods: This prospective study included 10 eyes of 10 patients with moderate-advanced keratoconus who underwent PD-DALK with Neoring implantation. Neoring was implanted in a pre-descemetic pocket. The post-operative examination included refraction, corrected distance visual acuity (CDVA), corneal tomography, and endothelial cell density (ECD). The root mean squares (RMSs) for coma-like aberrations and spherical aberration were evaluated for a pupil size of 4.5 mm. The junctional graft (Tg) and host (Th) thicknesses were measured. The post-operative follow-up was 24 months. Results: Post-operative CDVA was 0.82 ± 0.14 (decimal scale), 100% of the eyes achieved a CDVA of 0.7 (decimal scale). The refractive cylinder was −2.86 ± 1.65 2-years after surgery. No eyes had a post-operative refractive cylinder ≥5.00 D and in five eyes (50%), it was ≤2.50 D. At the last visit, the mean keratometry was 45.64 ± 1.96 D, the RMS for coma-like aberrations was 0.30 ± 0.15 μm and spherical aberration was 0.22 ± 0.09. The mean ECD remains without changes over the follow-up (P = 0.07). At the last visit, Tg and Th were 679.9 ± 39.0 and 634.8 ± 41.2 μm, respectively. The thickness of the complex (host-Neoring) was 740.6 ± 35.6 μm. In all cases, this thickness was thicker than Tg. Conclusion: The results of this study suggest that PD-DALK along Neoring implantation is a viable, effective, and safe option to optimize the post-operative results for moderate-severe keratoconus.
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Affiliation(s)
| | - Carlos Lisa
- Fernández-Vega Ophthalmological Institute, Universidad de Oviedo, Oviedo, Spain
| | | | - David Madrid-Costa
- Faculty of Optics and Optometry, Universidad Complutense de Madrid, Madrid, Spain
| | - José F Alfonso
- Fernández-Vega Ophthalmological Institute, Universidad de Oviedo, Oviedo, Spain
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Manual DALK in Keratoconus: An Ex Vivo Light and Transmission Electron Microscopy Analysis 2 Years After Surgery. Cornea 2021; 41:370-373. [PMID: 34038068 DOI: 10.1097/ico.0000000000002752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/13/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the microscopic structure of a human cornea 2 years after manual deep anterior lamellar keratoplasty (DALK) for keratoconus with a recipient residual stromal bed thickness of 100 μm, using light and transmission electron microscopy. METHODS A human cornea treated with manual DALK for keratoconus 2 years before was removed during penetrating keratoplasty because of stromal opacity of unknown origin, involving about half of the sample. The transparent half of the specimen was processed for light and transmission electron microscopy. RESULTS Light microscopy examination performed with different staining techniques (hematoxylin and eosin, Picrosirius red, and Masson trichrome) revealed a homogeneous stroma. No interface was detected. Electron microscopy confirmed these findings. CONCLUSIONS This study confirmed the available clinical and confocal studies that show progressive stromal remodeling after manual DALK. Two years after surgery, no posterior stromal interface was detected.
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Genc S, Emin Sucu M, Çakmak S, Yildirim Y, Kepez Yıldız B, Ağca A. Deep anterior lamellar keratoplasty techniques; predescemetic versus big bubble: Anterior segment optical coherence tomography study. J Fr Ophtalmol 2020; 43:222-227. [PMID: 31987676 DOI: 10.1016/j.jfo.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/24/2019] [Accepted: 08/19/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the visual and refractive outcomes and anterior segment optical coherence tomography (AS-OCT) findings of 2 different deep anterior lamellar keratoplasty (DALK) techniques in the treatment of advanced keratoconus with and without successful big bubble formation. METHODS In this retrospective comparative case series, data from 79 consecutive eyes of 69 patients who underwent either big bubble (group 1, n: 62) or manual DALK (group 2, n: 17) were analyzed. The visual and refractive results, keratometric values and residual stromal thickness were assessed. Patients were seen at 1, 3, 6 and 12 months after the procedure and 1 month after complete suture removal. RESULTS A big bubble was successfully obtained in 62 eyes (78.5%; group 1) and manual dissection was performed in the 17 remaining eyes (21.5%; group 2). The final best spectacle-corrected visual acuity (BSCVA) was 0.38 logMAR and 0.55 logMAR in Group 1 and 2, respectively (P<0.05). At the final visit, BSCVA≤0.30 logMAR was achieved in 80% and 60.8% of eyes in Groups 1 and 2, respectively (P<0.001). Groups 1 and 2 were comparable in terms of mean keratometry: 47.80D±2.81D (range, 41.30D to 54.2D) versus 45.90D±3.62D (range, 41.10D to 53.8 D), respectively; (P=0.56) and keratometric astigmatism: 3.81D± 2.1D (range, 1.0D to 6.20D) versus 3.56D±1.92D (range 1.2D to 6.85D), respectively; (P=0.40) at the final follow-up. The mean residual stromal thickness was 36.90±17.80μm in group 2. CONCLUSION The presence of residual posterior corneal stroma when big bubble formation is not successfully achieved in DALK is correlated with lower postoperative visual acuity.
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Affiliation(s)
- S Genc
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
| | - M Emin Sucu
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - S Çakmak
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Y Yildirim
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - B Kepez Yıldız
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - A Ağca
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Customized Toric Intraocular Lens Implantation in Eyes with Cataract and Corneal Astigmatism after Deep Anterior Lamellar Keratoplasty: A Prospective Study. J Ophthalmol 2018; 2018:1649576. [PMID: 30057802 PMCID: PMC6051070 DOI: 10.1155/2018/1649576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/19/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To investigate the effectiveness of toric intraocular lenses (IOLs) for treating corneal astigmatism in patients with cataract and previous deep anterior lamellar keratoplasty (DALK). Setting San Giovanni-Addolorata Hospital, Rome, Italy. Design Prospective interventional case series. Methods Patients undergoing cataract surgery after DALK for keratoconus were enrolled. Total corneal astigmatism (TCA) was assessed by a rotating Scheimpflug camera combined with Placido-disk corneal topography (Sirius; CSO, Firenze, Italy). A customized toric IOL (FIL 611 T, Soleko, Rome, Italy) was implanted in all eyes. One year postoperatively, refraction was measured, the IOL position was recorded, and vectorial and nonvectorial analyses were performed to evaluate the correction of astigmatism. Results Ten eyes of 10 patients were analyzed. The mean preoperative TCA magnitude was 4.92 ± 1.99 diopters (D), and the mean cylinder of the IOL was 6.18 ± 2.44. After surgery, the difference between the planned axis of orientation of the IOL and the observed axis was ≤10° in all eyes. The mean surgically induced corneal astigmatism was 0.35 D at 20°. The mean postoperative refractive astigmatism power was 1.13 ± 0.94 D; with respect to preoperative TCA, the reduction was statistically significant (p < 0.0001). The mean change in astigmatism power was 3.80 ± 1.60 D, corresponding to a correction of 77% of preoperative TCA power. Nine eyes out of 10 had a postoperative refractive astigmatism power ≤ 2D. Conclusions Toric IOLs can effectively correct corneal astigmatism in eyes with previous DALK. The predictability of cylinder correction is partially lowered by the variability of the surgically induced changes of TCA. This trial is registered with NCT03398109.
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Lu Y, Grisolia ABD, Ge YR, Xue CY, Cao Q, Yang LP, Huang ZP. Comparison of femtosecond laser-assisted descemetic and predescemetic lamellar keratoplasty for keratoconus. Indian J Ophthalmol 2017; 65:19-23. [PMID: 28300735 PMCID: PMC5369287 DOI: 10.4103/ijo.ijo_688_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The purpose of this study is to compare the outcomes following femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK) with 75% of stromal dissection (predescemetic group) and femtosecond laser-assisted DALK using big-bubble technique with total stromal resection (descemetic group) for the treatment of keratoconus. SUBJECTS AND METHODS Twenty eyes of 17 patients with keratoconus were studied. There were 10 eyes of 9 patients in predescemetic group and 10 eyes of 8 patients in descemetic group. The postoperative best-corrected visual acuity (BCVA), manifest refraction, keratometry, endothelial cell density (ECD), and central corneal thickness (CCT) were analyzed. RESULTS All surgeries were performed uneventfully. At 1 year after surgery, the BCVA, corneal astigmatism, keratometry, CCT, and ECD between two groups were not statistically significant (all P > 0.05). However, the mean manifest refraction was -9.43 ± 7.44 diopter (D) and -1.03 ± 1.13D in predescemetic and descemetic groups, respectively, which was statistically significant between two groups (P < 0.05). CONCLUSIONS The results of BCVA and corneal astigmatism, keratometry, ECD, and CCT were comparable between two groups. However, the mean postoperative manifest refraction was lower in descemetic group.
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Affiliation(s)
- Yan Lu
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Ana Beatriz Diniz Grisolia
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, MI 48105, Ann Arbor, MI 48105, USA
| | - Yi-Rui Ge
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Chun-Yan Xue
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Qian Cao
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Li-Ping Yang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Zhen-Ping Huang
- Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu Province, China
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Yüksel B, Kandemir B, Uzunel UD, Çelik O, Ceylan S, Küsbeci T. Comparison of visual and topographic outcomes of deep-anterior lamellar keratoplasty and penetrating keratoplasty in keratoconus. Int J Ophthalmol 2017; 10:385-390. [PMID: 28393029 DOI: 10.18240/ijo.2017.03.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 09/03/2016] [Indexed: 11/23/2022] Open
Abstract
AIM To compare visual, surgical and topographic outcomes of deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for keratoconus (KC). METHODS In this multicenter, prospective, randomized clinical trial 76 eyes of 71 KC patients operated between January 2011 and July 2014 in 2 tertiary referral hospitals were included. Consecutive patients were alternately selected to receive one of the two surgical methods. Thirty eight eyes underwent DALK with the big-bubble technique and 38 eyes underwent PK. RESULTS Mean best spectacle corrected visual acuity (BSCVA) at the first postoperative week (P=0.012) and the first postoperative month (P<0.001) was statistically significantly higher in DALK group. The mean BSCVA at 12mo was not significantly different for DALK (0.30±1.99 logMAR) versus PK (0.40±0.33 logMAR) (P=0.104). The 76.3% of the eyes had a BSCVA over 0.5 in DALK and 47.4% in PK group (P=0.009). The 7.9% of the eyes had a BSCVA of 1.0 in DALK and 5.3% in PK group (P=0.644). Mean spherical equivalent was -2.94 D in DALK and -3.09 D in PK group. Mean topographic astigmatism was 4.62 D and 4.18 D respectively. Regular topographic patterns were observed in 31 (81.6%) of DALK and 29 (76.3%) of PK (P=0.574). The most frequent topographic pattern was oblate asymmetric bow tie, seen in 39.5% in DALK and 23.7% in PK. CONCLUSION Big bubble DALK provides an earlier visual improvement compare to PK. However, visual and topographic outcomes are similar to those in PK at 1y. Postoperative complications including rejection and intraocular pressure elevation are more frequent in PK. DALK is a safer alternative to PK for KC. However, intraoperative perforation of the Descemet's membrane is a significant complication.
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Affiliation(s)
- Bora Yüksel
- Department of Ophthalmology, Izmir Bozyaka Training and Research Hospital, Izmir 35110, Turkey
| | - Baran Kandemir
- Department of Ophthalmology, Kartal Training and Research Hospital, Istanbul 34660, Turkey
| | - Umut Duygu Uzunel
- Department of Ophthalmology, Izmir Bozyaka Training and Research Hospital, Izmir 35110, Turkey
| | - Ozan Çelik
- Department of Ophthalmology, Izmir Bozyaka Training and Research Hospital, Izmir 35110, Turkey
| | - Sezgin Ceylan
- Department of Ophthalmology, Kartal Training and Research Hospital, Istanbul 34660, Turkey
| | - Tuncay Küsbeci
- Department of Ophthalmology, Izmir Bozyaka Training and Research Hospital, Izmir 35110, Turkey
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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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Parker J, van Dijk K, Melles G. Updates in anterior lamellar keratoplasty: the state of the debates. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1080/17469899.2016.1224656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Abstract
PURPOSE The goals of this laboratory study were to evaluate the interface quality in laser-assisted lamellar anterior keratoplasty (LALAK) with microkeratome-cut grafts and achieve good graft-host apposition. METHODS Simulated LALAK surgeries were performed on 6 pairs of eye-bank corneoscleral discs. Anterior lamellar grafts were precut with microkeratomes. Deep femtosecond (FS) laser cuts were performed on host corneas followed by excimer laser smoothing. Different parameters of FS laser cuts and excimer laser smoothing were tested. Optical coherence tomography was used to measure corneal pachymetry and evaluate graft-host apposition. The interface quality was quantified in a masked fashion using a 5-point scale based on scanning electron microscopy images. RESULTS Deep FS laser cuts at 226 to 380 μm resulted in visible ridges on the host bed. Excimer laser smoothing with a central ablation depth of 29 μm and saline as a smoothing agent did not adequately reduce ridges (score = 4.0). Deeper excimer laser ablation of 58 μm and Optisol-GS as a smoothing agent smoothed ridges to an acceptable level (score = 2.1). Same sizing of the graft and host cut diameters with an approximately 50-μm deeper host side cut relative to the central graft thickness provided the best graft-host fit. CONCLUSIONS Deep excimer laser ablation with a viscous smoothing agent was needed to remove ridges after deep FS lamellar cuts. The host side cut should be deep enough to accommodate thicker graft peripheral thickness compared with the center. This LALAK design provides smooth lamellar interfaces, moderately thick grafts, and good graft-host fits.
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