Outcome of deep anterior lamellar keratoplasty patients with intraoperative Descemet's membrane perforation: A retrospective cross-sectional study

Etiology-Specific Comparison of the Long-Term Clinical Outcome of Repeat Deep Anterior Lamellar Keratoplasty for Optical Indications

PURPOSE

The aim of this study was to evaluate the etiology-specific clinical outcomes and complications of repeat deep anterior lamellar keratoplasty (DALK) after failed DALK.

METHODS

This retrospective case study included 32 eyes of 27 patients who underwent repeat DALK of 450 cases of DALK performed for optical indications between 1997 and 2013. The patients were divided into 4 etiology-specific subgroups (the corneal dystrophy, ocular surface disease, stromal scar, and others) or those with or without limbal stem cell deficiency (LSCD). The clinical outcomes evaluated were graft survival, best-corrected visual acuity, endothelial cell density, and complications.

RESULTS

The mean postoperative follow-up duration was 69.6 ± 54.8 months. The 1-, 3-, and 5-year overall graft survival rate were 76.7%, 57.5%, and 38.8% respectively. The graft survival rate was the highest in the corneal dystrophy group ( P = 0.0014) and was significantly ( P = 0.0010) higher in eyes without LSCD than in eyes with LSCD. There were no significant differences in the graft survival rates between the previous and current DALK groups. The postoperative best-corrected visual acuity of all subjects improved significantly. The postoperative endothelial cell density did not decrease after repeat DALK. There were no significant differences in the incidence of complications between patients with and without LSCD, except the incidence of persistent epithelial defects.

CONCLUSIONS

Repeat DALK had favorable outcomes in all etiology-specific groups, whereas eyes with LSCD required careful assessment of the ocular surface to avoid graft failure due to persistent epithelial defects.

Complications in deep anterior lamellar keratoplasty – A retrospective cross sectional interventional analysis in a large series

AIM

To analyse complications in patients managed with deep anterior lamellar keratoplasty (DALK) for diseases of anterior corneal stroma.

MATERIALS AND METHODS

This was a retrospective analysis of all the patients who underwent DALK in a tertiary care center in South India from 2010 to 2021. A total of 484 eyes in 378 patients were included in the study. Patients who underwent DALK for advanced keratoconus, keratoconus with Bowman's membrane scar, healed hydrops, macular corneal opacity, macular corneal dystrophy, granular corneal dystrophy, spheroidal degeneration, pellucid marginal degeneration, post-LASIK ectasia, descemetocele, postcollagen cross-linking aborted melt and dense scar, and postradial keratotomy were included in the study. The patients were followed up for 17.6±9.4 months(1-10years).

RESULTS

Complications noted in the surgery were intraoperatively Descemet's membrane perforation in 32 eyes (6.6%), postoperatively secondary glaucoma in 16 eyes (3.31%), cataract in 7 eyes (1.45%), suture-related complications in 5 eyes (1.03%), graft rejection in 3 eyes (0.61%), traumatic dehiscence in 2 eyes (0.41%), filamentary keratitis in 2 eyes (0.41%), interface infiltrate in 1 eye (0.21%), and recurrence of disease in 4 eyes (8.77%) out of 57 eyes with corneal dystrophy.

CONCLUSION

DALK as an alternative to penetrating keratoplasty for anterior corneal stromal diseases has proven to be better time and again. It has become an automatic choice for diseases of anterior cornea requiring keratoplasty. Complications occurring at any stage of surgery can be identified and managed effectively resulting in optimal outcome. This article compiles complications post DALK.

Complications in deep anterior lamellar keratoplasty - A retrospective interventional analysis in a large series

Purpose

To analyze the complications in patients managed with deep anterior lamellar keratoplasty (DALK) for diseases of the anterior corneal stroma.

Methods

This is a retrospective analysis of all the patients who underwent DALK in a tertiary care center in South India from 2010 to 2020. A total of 474 eyes in 373 patients were included in the study. Patients who underwent DALK for advanced keratoconus, keratoconus with Bowman's membrane scar, healed hydrops, macular corneal opacity, macular corneal dystrophy, granular corneal dystrophy, spheroidal degeneration, pellucid marginal degeneration, post-laser-assisted in situ keratomileusis ectasia, descematocele, post-collagen cross-linking aborted melt and dense scar, and post-radial keratotomy were included in the study. The patients were followed up for 17.2 +/- 9.2 months (1-9 years).

Results

Complications noted in the surgery were intra-operatively Descemet's membrane perforation in 31 eyes (6.54%), post-operatively secondary glaucoma in 16 eyes (3.37%), cataract in seven eyes (1.47%), suture-related complications in five eyes (1.05%), graft rejection in three eyes (0.63%), traumatic dehiscence in two eyes (0.42%), filamentary keratitis in two eyes (0.42%), interface infiltrate in one eye (0.21%), and recurrence of disease in four eyes (7.14%) out of 57 eyes with corneal dystrophy.

Conclusion

DALK as an alternative to penetrating keratoplasty for anterior corneal stromal diseases. It has become an automatic choice for diseases of the anterior cornea requiring keratoplasty. Complications can occur at any stage of surgery; however, if identified and managed early, they can result in optimal outcome.

Outcomes of deep anterior lamellar keratoplasty and penetrating keratoplasty in keratoconic eyes with and without previous hydrops

PURPOSE

The study aims to compare outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) in keratoconic eyes with or without previous hydrops.

METHODS

Retrospective analysis of 211 eyes who received PK (group 1, n = 74 [history of hydrops: n = 33]) or DALK (group 2, n = 137 [history of hydrops: n = 9]) from 2012 to 2019 at the Department of Ophthalmology, University of Cologne, Germany. Analysis included best spectacle-corrected visual acuity (BSCVA), complications, immune reactions, graft survival and keratometry, and subgroup analyses for subjects with or without previous hydrops.

RESULTS

Follow-up was 34.0 ± 23.6 months in group 1 and 30.7 ± 22.5 months in group 2. No significant difference was found in the course of BSCVA between groups 1 and 2 (p = 0.182) and in postoperative BSCVA between eyes with and without previous hydrops, regardless of the surgical method (p = 0.768). Endothelial immune reactions occurred exclusively in group 1 and did not occur more frequently in eyes with previous hydrops (p = 0.377). A higher risk of complications for eyes with previous hydrops was observed (p = 0.022). There was no difference in astigmatism and maximum keratometry (K_max) preoperatively and postoperatively between eyes with and without history of hydrops.

CONCLUSION

The prognosis for visual outcome after keratoplasty including visual acuity, astigmatism, and K_max for keratoconic eyes with previous hydrops is as good as for keratoconic eyes without previous hydrops, irrespective of the surgical method. However, eyes after hydrops seem to have an increased risk of complications.

Rescue Technique to Solve Postoperative Refractory Double Anterior Chamber in Deep Anterior Lamellar Keratoplasty

PURPOSE

The purpose of this study was to describe a simple rescue technique to solve postoperative double anterior chamber refractory to rebubbling in deep anterior lamellar keratoplasty (DALK).

METHODS

This study analyzed consecutive patients who underwent DALK between June 2014 and March 2018 and required a postoperative reattachment of Descemet membrane because of macroperforation-led persistent double chambers. The technique entails placing anchoring sutures to attach Descemet membrane to the donor's posterior stroma. Anchoring sutures were removed within 1 month of surgery. The postoperative best spectacle-corrected visual acuity (BSCVA) [converted to logarithm of the minimum angle of resolution (logMAR) units], endothelial cell density (cells/mm2), graft survival, postoperative complications, and corneal astigmatism (diopters) were evaluated.

RESULTS

Five eyes from 5 patients were included in this study [5 women, 63.6 ± 6.0 yrs (32-80 yrs); mean follow-up duration, 72.0 ± 23.3 mo (30-100 mo)] (mean ± SD). The grafts survived successfully in all patients without primary or secondary graft failure. The best spectacle-corrected visual acuity improved from 1.26 ± 0.66 logMAR preoperatively to 0.25 ± 0.15 logMAR postoperatively (n = 5, P = 0.042). The endothelial cell density was 1468 ± 810 cells/mm2 at the last visit.

CONCLUSIONS

Macroperforation of Descemet membrane during DALK with incomplete removal of the stroma can lead to persistent double anterior chamber. This complication could be solved by the technique devised by this study.

Deep Anterior Lamellar Keratoplasty with Large Descemet's Membrane Perforation: Should We Stop Conversion to Penetrating Keratoplasty?

Purpose

To evaluate the outcome of eyes with large Descemet's membrane (DM) perforation during deep anterior lamellar keratoplasty (DALK).

Methods

A retrospective, interventional case series of 12 eyes with completed DALK, despite DM perforation larger than 4 mm in its widest dimension. The main outcome measures included graft clarity, endothelial cell density (ECD), corrected distance visual acuity (CDVA), and DM detachment.

Results

The mean age of patients was 26.8 ± 11.4 years. Preoperative pathology included keratoconus (n = 10), macular dystrophy (n = 1), and postmicrobial keratitis corneal scar (n = 1). The average size of DM perforation was 6.5 mm ± 1.3 mm. At the end of the follow-up period (median 15 months, range 6-53 months), the mean CDVA was 0.32 ± 0.09 logMAR and the mean ECD was 1830.8 ± 299.7 cells/mm². Nine patients (75%) developed DM detachments postoperatively and was managed by intracameral air injection once in six eyes, and twice in three eyes. Other complications included persistent localized stromal edema at the site of DM defect in one eye and Urrets Zavalia syndrome in one eye.

Conclusion

Completing DALK in eyes with large DM perforation provides good visual acuity, endothelial cell count and may be superior to penetrating keratoplasty regarding long-term graft survival if confirmed in future comparative studies.

Preferred practice pattern and observed outcome of deep anterior lamellar keratoplasty - A survey of Indian corneal surgeons

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).

Re-Endothelialization of Bare Stroma after Descemet's Detachment due to Macroperforation during Deep Anterior Lamellar Keratoplasty

Purpose

To report a case with spontaneous re-endothelialization of bare stroma after subtotal detachment of Descemet's membrane (DM) due to macroperforation during deep anterior lamellar keratoplasty (DALK).

Methods

Case report.

Results

A 64-year-old patient underwent DALK for deep stromal scarring secondary to herpetic keratitis. During manual dissection, DM macroperforation occurred, and this was successfully managed intraoperatively and postoperatively. The DM with host posterior stroma remained attached for 10 months when it detached from the bare donor stroma. The cornea remained clear, with uncorrected distance visual acuity (UCVA) of 0.17 logMAR. After graft suture removal 30 months later, he was noted to have regular astigmatism and cataract for which he underwent phacoemulsification with toric intraocular lens implantation. Twenty-four months following his cataract surgery and 58 months following his DALK, his UCVA remains 0.17 logMAR and the cornea remains clear with no evidence of edema. His average specular count at 58 months was 1296 cell/mm² .

Conclusion

This case shows a very good visual outcome with clear cornea at 58 months despite of large DM detachment which happened 10 months following manual DALK with intraoperative macroperforation.

Five-year Outcomes of Converted Mushroom Keratoplasty from Intended Deep Anterior Lamellar Keratoplasty (DALK) Mandate 9-mm Diameter DALK as the Optimal Approach to Keratoconus

PURPOSE

To compare the 5-year outcomes of 9-mm-deep anterior lamellar keratoplasty (DALK) for keratoconus with those of conversions to mushroom keratoplasty (MK).

DESIGN

Retrospective cohort study.

METHODS

The setting was the Ospedali Privati Villa Igea, Department of Ophthalmology, Forlì, Italy. The study population consisted of the medical records of all attempted DALK procedures (416 eyes) for the indication of keratoconus performed between January 2012 and January 2018; 68 eyes (16.4%) were converted to MK and analyzed as a separate cohort. The mean follow-up time was 33.8 ± 15.1 months. Procedure(s) consisted of 9-mm DALK and MK (9-mm anterior lamella with 6-mm posterior lamella). Outcome measurements were best-corrected visual acuity (BCVA), refractive astigmatism, and endothelial cell loss (ECL) at 5 years.

RESULTS

Average BCVA at 5 years was 0.06 ± 0.07 in the DALK group and 0.09 ± 0.15 in the MK group (P = .88). Refractive astigmatism following suture removal (all visits later than 12 months) was slightly less in the DALK cohort (5-year DALK = 2.16 ± 1.40 diopter [D]; MK = 3.02 ± 0.89 D; P = .04; mean difference = 0.86 D [95% confidence interval [CI]: 0.71-1.01]). ECL was significantly higher in the MK group than in the DALK group at all follow-up intervals (5-year DALK = 19.36 ± 21.47%; MK = 56.61 ± 15.82%; P < .001). The total all-cause graft failure rate at 5 years was 0.58% for DALK (2 of 348) cases and 5.88% for MK (4 of 68) cases.

CONCLUSIONS

Excellent 5-year visual and clinical outcomes associated with a 2-piece MK in cases converted from intended DALK mandate large-diameter DALK (9 mm) as the optimal surgical approach to keratoconus.

Factors Predictive of Double Anterior Chamber Formation Following Deep Anterior Lamellar Keratoplasty

PURPOSE

To identify risk factors predictive of postoperative double anterior chamber formation after deep anterior lamellar keratoplasty (DALK).

DESIGN

Retrospective institutional cohort study.

METHODS

The study group included all consecutive eyes undergoing primary DALK between May 2015 and October 2018 at Villa Igea private hospital (Forli, Italy). The indications for surgery were categorized as (1) keratoconus without scarring; (2) keratoconus with scarring; (3) non-keratoconus without scarring; and (4) non-keratoconus with scarring. Multivariate binary logistic regression analysis was performed, introducing, as independent variables, those that reached a significance level of less than .05 in univariate analysis. The main outcome measure was whether or not postoperative double anterior chamber (AC) occurred.

RESULTS

A total of 591 eyes of 591 patients were included. The main indication for DALK was keratoconus (67.2%, n = 397), and pneumatic dissection was achieved in 72.9% (n = 431) of patients. Postoperative double AC was observed in 8.1% (n = 48) of cases. Age, intraoperative central DM perforation, type 2 bubble formation, and presence of scar in keratoconic and nonkeratoconic corneas were all associated with an increased risk of postoperative double AC formation in the univariate analysis. Manual dissection was not associated with double AC formation. The factors that remained significant in multivariate analysis were keratoconus with scarring (odds ratio [OR] = 3.56, P = .02), non-keratoconus with scarring (OR = 5.09, P = .002), intraoperative central perforation (OR = 6.09, P = .03), and type 2 bubble formation (OR = 14.17, P < .001).

CONCLUSIONS

Scarred corneas of both normal and abnormal shape are independent risk factors for double AC formation following DALK, along with intraoperative perforation and the occurrence of a type 2 bubble.