deep anterior lamellar keratoplasty in children world cornea congress april 2010 boston, ma asim...
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Deep anterior lamellar Deep anterior lamellar keratoplasty in childrenkeratoplasty in childrenWorld Cornea Congress April 2010Boston, MA
Asim Ali, MD, FRCSCUniversity of TorontoHospital for Sick ChildrenToronto, Ontario, Canada
Disclosure: The author has no financial interests related to the material of this poster.
AbstractAbstractPurposeTo present a series of pediatric patients who underwent deep anterior lamellar keratoplasty (DALK) for stromal opacities or ectasia by one surgeon from 2007-2009. MethodsA retrospective review of 12 consecutive patients with attempted DALK, age less than 18 years and follow-up of at least 4 months was performed. Indications for surgery, length of follow-up, complications and initial and final visual acuity were recorded. Results Successful DALK was performed in 12 eyes of 11 patients aged 1-17 years old. There was one macroperforation and conversion to penetrating keratoplasty. Non-healing epithelial defects occurred in 2 patients who developed microbial keratitis. Repeat DALKs were performed successfully. One patient developed reactivation of HSV in the graft and because of dense amblyopia a repeat graft was not attempted. Final visual acuity was unchanged or improved in all patients. ConclusionsDeep anterior lamellar keratoplasty is a safe alternative to penetrating keratoplasty in children with corneal stromal opacities or ectasia.
MethodsMethodsRecords of 13 eyes of 12
consecutive patients with attempted DALK were reviewed
Single surgeon from 2007-09Surgical technique used
◦Melles technique (1 case)◦Manual dissection (12 cases)
Trephination (Hessberg-Barron, 300-350 microns)
Sharp and semi-sharp dissection to pre-Descemet’s plane
Air injected to visualize stroma but big bubble not attempted
ResultsResults12/13 eyes underwent successful manual
DALK1 eye was converted to PKP because of
macroperforation4 microperforations occurred but
dissection was completed successfully2 repeat DALKs (with tarsorraphy) were
performed after persistent epithelial defects resulted in bacterial keratitis – both remain clear
Vision remains unchanged or improved in all patients
Grafts are clear in 11/12 eyes with mean follow-up of 11.8 months (range 6-22)
Table 1: Pre-operative Table 1: Pre-operative characteristicscharacteristicsPatient
Age Eye
Diagnosis Other Pre-op BCVA
1 9 mo RE Herpes simplex CS UM*
2 9 yr RE Phlectenulosis 20/400
3 14 yr
RE Keratoconus Autism, eye-rubber Fix + follow
14 yr
LE Keratoconus Fix + follow
4 15 yr
RE Hurler syndrome 20/200
5 1 yr LE Corneal dermoid Linear nevus sebaceous
CS UM*
6 8 yr LE ? Herpes zoster 20/100
7 2 yr LE Bacterial keratitis Neurotrophic cornea LP
8 16 yr
LE Keratoconus Eye-rubber, OCD, Tourettes
CF
9 8 yr RE Descemetocele Posterior blepharitis 20/40
10 14 yr
LE Bacterial keratitis Soft contact lens wearer
20/70
11 5 yr RE Exposure keratopathy
Goldenhar syndrome, lid coloboma repair
20/800
12 13 yr
LE Keratoconus CF
* Central, steady + unmaintained
Table 2: Operative detailsTable 2: Operative detailsPatient
Eye
Residual opacity
Donor/recipient (mm)
Intraoperative complications / comments
1 RE - - Macroperforation, converted to PKP
2 RE No 7.75 /7.5 None
3 RE No 7.75 /7.5 None
LE No 8.0 /7.5 None
4 RE Yes 8.0 /7.5 Microperforation
5 LE No 7.0 /6.5 Previous crescentic graft, subsequent cataract extraction /IOL /pupilloplasty
6 LE Yes 8.0 /7.5 Microperforation
7 LE No 7.25 /7.0 None
8 LE No 8.5 /8.0 None
9 RE Yes 7.75 /7.5 Microperforation
10 LE No 8.25 /8.0 Microperforation
11 RE No 7.75 /7.5 None
12 LE No 8.0 /7.5 None
Table 3: Post-operative courseTable 3: Post-operative coursePatient
Eye
Complications Post-op BCVA
Follow-up
Comments
1 RE Graft rejection 20/200
2 RE None 20/40 22 mo Ambylopia
3 RE None 20/40 12 mo
LE None 20/50 6 mo
4 RE None 20/80 6 mo Sutures in
5 LE None 20/200 20 mo Dense amblyopia
6 LE Suture loosening at 6 weeks
20/60 11 mo Amblyopia
7 LE ? HSV reactivation + scar
HM 13 mo Opted not to regraft
8 LE None 20/40 8 mo
9 RE Persistent epi defect, bacterial ulcer, regraft
20/40 22 mo Tarsorraphy
10 LE None 20/20 12 mo
11 RE Persistent epi defect, bacterial ulcer, regraft
20/200 14 mo Amblyopia
12 LE None 20/50 6 mo
Figure 1: Slit lamp photo of patient 6showing anterior stromal scar and thinning
Figure 2: Slit lamp photo of patient 12 showing Vogt striae and deep scarring
DiscussionDiscussionDALK was selected instead of PKP in our pediatric patients
because of a lower risk of rejection and greater tectonic strength. Two of our patients (3 and 8) were forceful eye rubbers with psychiatric co-morbidities and the improved strength was reassuring.
A manual technique instead of a big bubble technique was used to allow dissection of deep scars and minimize perforations, as we believe the benefit of reduced rejection outweighs the visual benefits in this patient group with other ocular co-morbidities especially amblyopia.
The high rate of perforation may reflect the deep scarring in some corneas and also surgeon inexperience.
Satisfactory visual outcomes were achieved even when residual corneal opacities remained in the recipient bed.
Persistent epithelial defects lead to bacterial superinfection in two patients and we now perform temporary and permanent tarsorraphies following DALK surgery in susceptible patients.
ConclusionsConclusionsManual DALK in children leads to
improved visual outcomes, and in our view has significant advantages over PKP in this high risk group.