Deep Anterior Lamellar Keratoplasty in Patients With Full-

Thickness Corneal PathologiesDr Charmaine Chai

Dr Ray ManotoshDr Anna Marie Tan

Prof Donald TanNational University Hospital

The authors have no financial interests to disclose

To present our intra-operative, and post-operative outcomes of patients who underwent manual Deep Anterior Lamellar Keratoplasty (DALK) for full thickness corneal pathologies.

Purpose

Retrospective case series Case records of all patients who underwent

a keratoplasty from 2011 to 2014 in the National University Hospital (NUH) were reviewed and

Patients who underwent a DALK for various full-thickness corneal pathologies were identified

Methods

Outcome measurements recorded include intra-operative and post-operative complications, and best-corrected visual acuity (BCVA).

Surgical technique and details of intra-operative findings were recorded.

All donor corneas were obtained from the Singapore Eye Bank and graded using the Singapore Eye Bank grading system.

Methods

Of the 140 keratoplasties performed in NUH, 38 were DALKs (27.1%).

7 patients underwent a DALK by a single surgeon (Professor Donald Tan) between June 2012 and August 2014◦ 5 patients had significant corneal scarring from

previous full thickness corneal laceration repairs◦ 2 patients presented with corneal perforation, 1

secondary to active marginal keratitis, while the other secondary to a sterile corneal ulcer from blepharokeratitis and chronic use of topical steroids

Results

Intra-operatively, 5 out of 7 patients (71.4%) had inadvertent DM perforation with entry into the anterior chamber. ◦ None of the cases had a persistent double anterior chamber that

required surgical intervention. Of the 6 patients who were seen at least 6 months after

surgery, 4 patients (66.7%) achieved a BCVA of 6/12 (LogMAR 0.3) or better. ◦ 1 patient was still aphakic (LogMAR 3) at last follow-up◦ 1 patient had a residual posterior stromal scar with high

astigmatism (LogMAR 0.88) There were no cases of graft rejection by last follow-up The longest follow-up was at 30 months post-operatively,

of which the graft remained clear

Results

Figure 2 – Post-operative anterior segment photographs at week 1 (A) and month 4 (B)

Figure 1 – Pre-operative anterior segment photograph of a patient who presented with a corneal perforation secondary to Blepharokeratitis and chronic topical steroid use.

Figure 3 – Pre-operative photographs of the right (A) and left (B) eye of the patient who presented with a perforated corneal ulcer secondary to recurrent marginal keratitis

Figure 4 – Post-operative anterior segment photographs of the left eye at month 21

Traditionally, the decision to perform a DALK versus a PK is based on the corneal endothelium health.

With improved instrumentation and surgical techniques, DALK can be performed with good visual outcomes.

By avoiding a full thickness keratoplasty, we believe that we have significantly decreased the risk of endothelial rejection and other associated risks of a PK.

Discussion

High incidence of DM perforation is not unexpected given the nature of the cases that were selected.

Though a double anterior chamber may be seen in the initial post-operative phase, all eventually resolved with no need for surgical intervention

In the event of DM perforation, small amount of residual stromal may be left behind.

Good visual outcome can still be achieved if the pathological area is mostly excised and the central visual axis is relatively clear and almost down to the DM.

Discussion

DALK can be performed as an alternative surgical procedure even in the presence of a defective descemet membrane.

Good visual outcome and minimal post-operative complications can be achieved with modifications and improvements in surgical techniques.

Conclusion

1. Luengo-Gimeno F, Tan DT, Mehta JS: Evolution of deep anterior lamellar keratoplasty (DALK). The ocular surface 2011, 9(2):98-110.

2. Barraquer JI: Lamellar keratoplasty. (Special techniques). Annals of ophthalmology 1972, 4(6):437-469.

3. Kubaloglu A, Sari ES, Unal M, Koytak A, Kurnaz E, Cinar Y, Ozerturk Y: Long-term results of deep anterior lamellar keratoplasty for the treatment of keratoconus. American journal of ophthalmology 2011, 151(5):760-767.e761.

4. Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM: Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmology 2011, 118(1):209-218.

5. Sarnicola V, Toro P, Gentile D, Hannush SB: Descemetic DALK and predescemetic DALK: outcomes in 236 cases of keratoconus. Cornea 2010, 29(1):53-59.

6. Ang M, Mohamed-Noriega K, Mehta JS, Tan D: Deep anterior lamellar keratoplasty: surgical techniques, challenges, and management of intraoperative complications. International ophthalmology clinics 2013, 53(2):47-58.

7. Sugita J, Kondo J: Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. The British journal of ophthalmology 1997, 81(3):184-188.

8. Anwar M, Teichmann KD: Deep lamellar keratoplasty: surgical techniques for anterior lamellar keratoplasty with and without baring of Descemet's membrane. Cornea 2002, 21(4):374-383.

References