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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] [MESH Headings] [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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Yu AC, Sollazzo A, Bovone C, Busin M. Large-diameter deep anterior lamellar keratoplasty: A narrative review. Taiwan J Ophthalmol 2024; 14:27-33. [PMID: 38654986 PMCID: PMC11034690 DOI: 10.4103/tjo.tjo-d-23-00161] [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: 10/23/2023] [Accepted: 01/01/2024] [Indexed: 04/26/2024] Open
Abstract
Deep anterior lamellar keratoplasty (DALK) involves the selective replacement of diseased corneal stroma while preserving healthy unaffected endothelium. While DALK has failed to gain widespread popularity, improved visual and refractive outcomes of large-diameter grafts, which patients directly perceive following suture removal, may represent a compelling reason to shift toward DALK. Since the unaffected host endothelium is retained, DALK offers the opportunity to use large-diameter grafts, which reliably achieves maximum visual potential without an increased risk of immune-mediated stromal rejection. In this narrative review, we evaluate the current evidence on large-diameter DALK including surgical technique and clinical outcomes.
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Affiliation(s)
- Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì “Villa Igea”, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Andrea Sollazzo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì “Villa Igea”, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Cristina Bovone
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì “Villa Igea”, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì “Villa Igea”, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
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Du K, Liu E, Li N, Yuan B, Peng R, Hong J. Comparison of Femtosecond Laser Assistance and Manual Trephination in Deep Anterior Lamellar Keratoplasty in the Treatment of Keratoconus: A Meta-Analysis. Am J Ophthalmol 2023; 256:126-137. [PMID: 37553035 DOI: 10.1016/j.ajo.2023.08.003] [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: 02/13/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To compare the efficacy and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty (F-DALK) with those of manual-trephination DALK (M-DALK) in treating keratoconus. DESIGN Systematic review and meta-analysis. METHODS Through November 2022, we comprehensively searched PubMed, EMBASE, the Cochrane Library, and 4 Chinese databases. Studies that involved comparisons between F-DALK and M-DALK groups and that reported on relevant efficacy and/or safety parameters were included. Primary outcomes were uncorrected- and corrected-distance visual acuity and intraoperative complication rates. Secondary outcomes were spherical equivalent, topographic astigmatism, refractive cylinder, mean keratometry, endothelial cell density, suture removal time, and postoperative complication rates. These data were analyzed using Cochrane Review Manager software version 5.3. RESULTS This meta-analysis included 9 nonrandomized controlled studies involving 1713 eyes. In eyes treated with F-DALK, corrected-distance visual acuity at 1 to 6 months (weighted mean difference = -0.07 [95% confidence interval {CI} -0.10 to -0.03]; I2 = 0%; P < .001) after surgery was better and intraoperative Descemet membrane perforation occurred less often (odds ratio = 0.53 [95% CI 0.31-0.92]; I2 = 6%; P = .02) than in eyes treated with M-DALK. No clinically significant differences in other outcomes were found among the groups. CONCLUSIONS Both F-DALK and M-DALK are safe and efficacious for patients with keratoconus. Compared with M-DALK, F-DALK can provide better early visual acuity and reduce the intraoperative perforation rate, and its likely improvements to long-term visual quality and endothelial cell preservation warrant further investigation. In addition, the 2 techniques seem to be comparable regarding refractive outcomes and other complications.
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Affiliation(s)
- Kaiyue Du
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Enshuo Liu
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Nan Li
- Peking University Third Hospital (N.L.), Beijing, China
| | - Bowei Yuan
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Rongmei Peng
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Jing Hong
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China.
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Moumneh K, Pollack S, Perich LM. Deep Anterior Lamellar Keratoplasty Over Penetrating Keratoplasty to Mitigate Positive Vitreous Pressure Complications. Cureus 2023; 15:e51120. [PMID: 38274923 PMCID: PMC10808883 DOI: 10.7759/cureus.51120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 01/27/2024] Open
Abstract
This report describes deep anterior lamellar keratoplasty over penetrating keratoplasty (DALK-over-PKP) as an alternative technique to mitigate complications related to positive vitreous pressure (PVP) during PKP. We accomplished this by repairing the punctured cornea and performing a modified DALK where a full-thickness donor graft is placed over the host Descemet membrane, which is then removed after partial suturing of the graft. This mitigates the driving force behind the PVP by maintaining a closed-anterior chamber.
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Affiliation(s)
- Khaled Moumneh
- Ophthalmology, HCA Florida Bayonet Point Hospital, Hudson, USA
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Mishra S, Joshi A, Ginu P, Sati A, Kumar SV. Corneal transplantation: A walk to vision. Med J Armed Forces India 2023; 79:645-650. [PMID: 37981925 PMCID: PMC10654358 DOI: 10.1016/j.mjafi.2023.08.010] [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: 07/08/2023] [Accepted: 08/19/2023] [Indexed: 11/21/2023] Open
Abstract
Corneal diseases are a major cause of blindness in the world. Corneal transplantation has been a cornerstone in the management of several of these advanced pathologies. This article discusses the evolution of corneal transplantation over a century, its indications, complications and briefly the various surgical techniques. Such tremendous technical improvisations from total corneal transplantation to lamellar keratoplasties have generated significant interest in the ophthalmic world and garnered momentum to the fight against blindness. Armed Forces Medical Services are also in vogue more than ever in this forward surge.
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Affiliation(s)
- S.K. Mishra
- Consultant & Head (Ophthalmology), Army Hospital (R & R), Delhi Cantt, India
| | - Amrita Joshi
- Graded Specialist (Ophthalmology), Army Hospital (R & R), Delhi Cantt, India
| | - P.M. Ginu
- Graded Specialist (Ophthalmology), Military Hospital Hisar, Hisar Cantt, India
| | - Alok Sati
- Senior Adviser (Ophthalmology), Army Hospital (R & R), Delhi Cantt, India
| | - Sonali V. Kumar
- Associate Professor (Ophthalmology), Army Hospital (R & R), Delhi Cantt, India
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Gabison EE, Gree E, Azar G, Cochereau I, Guindolet D. Double-Docking Technique for Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty: A Retrospective Consecutive Case Series Study of Advanced Keratoconus. Cornea 2023; 42:1052-1056. [PMID: 37155354 PMCID: PMC10306333 DOI: 10.1097/ico.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/25/2023] [Accepted: 03/06/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE The aim of this study was to report the clinical outcomes and prognosis of femtosecond laser (FSL)-assisted double-docking deep anterior lamellar keratoplasty (DD-DALK) for advanced keratoconus (AK). METHODS Records of consecutive patients with keratoconus who underwent FSL-assisted DALK (DD-DALK) were reviewed. RESULTS We analyzed 37 eyes from 37 patients who underwent DD-DALK. Sixty-eight percent of eyes had a successful big-bubble formation and 27% had a manual dissection to achieve the DALK deep dissection. Stromal scarring was associated with not achieving a big bubble. Intraoperative conversion to penetrating keratoplasty was conducted in 2 cases (5%). The best-corrected visual acuity improved from a median (± interquartile range) of 1.55 ±0.25 logMAR preoperatively to 0.2 ±0.2 logMAR ( P < 0.0001). The median postoperative spherical equivalent was -5.75 ±2.75 D with a median astigmatism of -3.5 ±1.3 D. BCVA, SE, and astigmatism were not statistically different between patients who underwent DD-DALK and patients who underwent manual DALK. Stromal scarring was associated with big-bubble (BB) formation failure ( P = 0.003). All patients with failed BB requiring manual dissection had anterior stromal scarring. CONCLUSIONS DD-DALK is safe and reproducible. The success rate of BB formation is hampered by stromal scarring.
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Affiliation(s)
- Eric E. Gabison
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
| | - Eva Gree
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
| | - Georges Azar
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
| | - Isabelle Cochereau
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
- Ophthalmology Department, Bichat Claude-Bernard Hospital, Paris, France; and
- Université de Paris, Paris, France
| | - Damien Guindolet
- Ophthalmology Department, Rothschild Ophthalmic Foundation Hospital, Paris, France
- Ophthalmology Department, Bichat Claude-Bernard Hospital, Paris, France; and
- Université de Paris, Paris, France
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Update on Femtosecond Laser-Enabled Keratoplasty. Cornea 2023; 42:395-403. [PMID: 36538423 DOI: 10.1097/ico.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/01/2022] [Indexed: 12/24/2022]
Abstract
ABSTRACT The application of femtosecond lasers to corneal transplantation is an intriguing proposition with many potential benefits to patients with various corneal diseases. The customized trephination pattern for donor and host matching offers many advantages regarding wound integrity and high precision of donor and recipient match at the interface, which should lead to faster healing and visual rehabilitation. Femtosecond laser-enabled keratoplasty (FLEK) is an advancement of conventional trephination penetrating keratoplasty, and in large clinical cohorts to date, there are meaningful improvements in visual outcomes and a lower risk of graft rejection. Femtosecond laser-enabled deep anterior lamellar keratoplasty (Femto-DALK) combines the advantage of a customized trephination pattern with the deep anterior lamellar keratoplasty procedure, which eliminates the risk of endothelial rejection. Furthermore, the precision of the femtosecond laser may offer additional novel approaches to lamellar keratoplasties. In time, advancements in femtosecond laser platforms will help cornea surgeons realize the added benefits and better optimize outcomes for patients, such that the cost-benefit calculus shifts toward wider accessibility for patients. Prospective randomized-controlled trials are needed to definitively determine the impact of femtosecond laser-enabled keratoplasties on long-term outcomes.
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Muacevic A, Adler JR. A Review of Corneal Blindness: Causes and Management. Cureus 2022; 14:e30097. [PMID: 36381769 PMCID: PMC9643016 DOI: 10.7759/cureus.30097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/09/2022] [Indexed: 01/25/2023] Open
Abstract
Corneal blindness refers to a group of eye disorders that change the corneal transparency, causing corneal scarring and blindness. The leading causes of corneal blindness include infectious causes, i.e., due to bacteria, viruses, fungi, and protozoa. The most common predisposing factors are trauma, contact lens usage, or the use of steroid medications. The various other diseases included are trachoma, dry eye disease, keratoconus, ophthalmia neonatorum, and non-infectious uveitis. Various clinical modalities are used for treating corneal blindness, including organ transplantation. Organ donation is cumbersome as various ethical and other factors are involved. Hence the concept of eye banking was introduced to meet the increasing demand for donors of the cornea. The eye bank's role is harvesting, processing, and keeping a record of the cornea being transplanted and donated. Furthermore, various recent advancements have been made for lamellar keratoplasty surgeries, including bioengineered corneas to fulfil the need for the unavailability of donors for the cornea. Various specific health interventions have been implemented to reduce the prevalence of corneal blindness globally. For proper management of corneal blindness, we have three components that are needed to be taken care of: prevention of corneal blindness, appropriate treatment modalities, and providing adequate rehabilitation services to the patients. This review encompasses the main reasons for corneal blindness and the management and treatment modalities available for the patients. The terms cornea, corneal blindness, treatment, management, causes, and complications were used for the review article on PubMed.
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Yu AC, Spena R, Pellegrini M, Bovone C, Busin M. Deep Anterior Lamellar Keratoplasty: Current Status and Future Directions. Cornea 2022; 41:539-544. [PMID: 34759197 DOI: 10.1097/ico.0000000000002840] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Deep anterior lamellar keratoplasty (DALK) involves selective replacement of diseased corneal stroma while preserving normal healthy endothelium. Despite several well-recognized advantages, the uptake of DALK has remained sluggish with an adoption rate that has plateaued over the past decade. Misconceptions such as the rarity of complications of penetrating keratoplasty, lack of standardization of the DALK technique, and limited substantial benefit in visual and refractive outcomes are frequently cited as arguments against performing DALK. This brief review discusses the recent findings that refute these perceived barriers; describes contemporary techniques, tools, and modifications in the surgical approach; and evaluates the evidence regarding the clinical outcomes of DALK.
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Affiliation(s)
- Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Rossella Spena
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Marco Pellegrini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Cristina Bovone
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì"Villa Igea", Forlì, Italy ; and
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
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10
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Wong YL, Liu S, Walkden A. Current Perspectives on Corneal Transplantation (Part 2). Clin Ophthalmol 2022; 16:647-659. [PMID: 35282168 PMCID: PMC8904263 DOI: 10.2147/opth.s349582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
Disease of the cornea is the third leading cause of blindness worldwide. Corneal graft surgery is one of the most successful forms of solid organ transplantations in humans, with ever increasing developments in surgical technique. To date, approximately 4504 corneal transplants are performed in the UK each year. While full thickness transplantation was the most commonly performed keratoplasty over the last few decades, selective lamellar transplantation of the diseased layers of the cornea has been universally adopted. This comprehensive review aims to provide an updated synthesis on different types of corneal transplantations, their treatment outcomes, and the associated complications of each procedure both in adult and pediatric populations. In addition, we also present an up-to-date summary of the emerging therapeutic approaches that have the potential to reduce the demand for donor-dependent keratoplasty.
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Affiliation(s)
- Yee Ling Wong
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Siyin Liu
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Andrew Walkden
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Correspondence: Andrew Walkden, Manchester Royal Eye Hospital, Oxford Road, Manchester, M13 9WL, UK, Email
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11
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Femtosecond laser-assisted big bubble for deep anterior lamellar keratoplasty. J Cataract Refract Surg 2021; 47:106-110. [PMID: 32932372 DOI: 10.1097/j.jcrs.0000000000000400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the utility of a femtosecond laser-assisted stromal channel to assist the creation of a big bubble (BB) for deep anterior lamellar keratoplasty (DALK) surgery in cadaveric corneas. SETTING L V Prasad Eye Institute, Hyderabad, India. DESIGN Experimental study. METHODS An attempt to create a BB was made on 10 donor pairs of human cadaveric corneoscleral tissues. The 20 corneas were split into 2 groups: Group A underwent femtosecond laser pretreatment and Group B had conventional manual deep lamellar technique. Laser pretreatment was performed using the VisuMax femtosecond laser system to create a stromal channel using the intracorneal ring segment treatment module for direct insertion of the 27-gauge air cannula for pneumodissection at a predetermined depth. RESULTS Of the 20 corneas studied, type 1 BB was achieved in 9 of 10 corneas in Group A and in 7 of 10 corneas in Group B. One cornea from Group A had a combined type 1 and 2 BB, whereas no BB was achieved in 1 cornea. CONCLUSIONS Creation of an intrastromal channel using a femtosecond laser at a predetermined depth seemed to be a promising option to increase the chances of achieving a BB when compared with the conventional air injection technique of BB DALK.
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12
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Sioufi K, Zheleznyak L, MacRae S, Rocha KM. Femtosecond Lasers in Cornea & Refractive Surgery. Exp Eye Res 2021; 205:108477. [PMID: 33516763 DOI: 10.1016/j.exer.2021.108477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 11/18/2022]
Abstract
Since the introduction of femtosecond laser (FS) systems for corneal flap creation in laser-assisted in-situ keratomileusis there have been numerous applications for FS laser in corneal surgery. This manuscript details the utility of FS lasers in corneal surgical procedures including refractive laser surgeries, intracorneal ring segment tunnels, presbyopic treatments, and FS-assisted keratoplasty. We also review the role of FS lasers in diagnostic procedures such as two photon excitation fluorescence and second harmonic generation.
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Affiliation(s)
- Kareem Sioufi
- Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA
| | | | - Scott MacRae
- Flaum Eye Institute and the Institute of Optics, University of Rochester, Rochester, NY, USA
| | - Karolinne M Rocha
- Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA.
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13
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Deshmukh R, Stevenson LJ, Vajpayee RB. Laser-assisted corneal transplantation surgery. Surv Ophthalmol 2021; 66:826-837. [PMID: 33524460 DOI: 10.1016/j.survophthal.2021.01.009] [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: 07/17/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
Corneal transplant surgeries have a broad range of indications with outcomes largely dependent on surgeon experience. Traditional manual techniques have certain limitations pertaining to the preparation of donor tissue and the recipient bed that might affect the predictability of visual outcomes. Use of lasers for keratoplasty procedures not only improves the repeatability and consistency of the technique, but also enables the surgeon to control the thickness and shape of the transplant tissue tailored to the specific condition. Despite the advantages, cost-effectiveness and technical know-how remain the major challenges. We discuss the various techniques of laser-assisted keratoplasties with respect to their methods, precision, and efficacy in various corneal indications.
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Affiliation(s)
- Rashmi Deshmukh
- Division of Ophthalmology and Visual Sciences, Eye ENT Centre, Queens Medical Centre, University of Nottingham, UK.
| | | | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Vision Eye Institute, Melbourne, Australia; University of Melbourne, Australia
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14
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Comparison of the effects of femtosecond laser energy on corneal endothelium at two different dissection levels in femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus. Int Ophthalmol 2021; 41:1167-1177. [PMID: 33398508 DOI: 10.1007/s10792-020-01669-x] [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: 07/03/2020] [Accepted: 11/27/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The objective of this study is to compare the endothelial safety of femtosecond laser (FSL) energy at two different dissection depths in FSL-assisted deep anterior lamellar keratoplasty (FSDALK) for keratoconus. METHODS This prospective double-armed interventional study included 25 eyes from 21 patients with advanced keratoconus who underwent FSDALK (big bubble technique) at a trephination depth of 110 µm in group I (11 eyes) and 80 µm in group II (14 eyes)-all of which were anterior to the Descemet's membrane (DM). Visual acuity measurement, anterior and posterior segment examination, corneal tomography, and specular microscopy were performed preoperatively and at 3, 6, and 12 months, postoperatively. Endothelial cell density, coefficient of variation, percentage of cell hexagonality, and pachymetry were used to evaluate endothelial safety. RESULTS No statistically significant difference in any of the endothelial safety parameters was found between the two groups. The mean 12-month postoperative endothelial cell loss rate was 17.46% and 12.91% in group I and II, respectively (P = 0.345). Most of the endothelial cell loss occurred during the first 3 months after surgery. Group II showed statistically greater improvement in the mean keratometry values at all follow-up visits. CONCLUSION The endothelial safety profiles of lamellar FSL cuts at 110 µm and 80 µm anterior to the DM are comparable. Cuts as deep as 80 µm anterior to the DM can be safely applied without causing significant injury to the endothelium. Further studies are needed to compare the endothelial safety profiles of different FSL platforms available in the market. Trial registration PACTR201901615323963. Registered 24 November 2018-retrospectively registered.
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Gadhvi KA, Romano V, Fernández-Vega Cueto L, Aiello F, Day AC, Gore DM, Allan BD. Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty for Keratoconus: Multi-surgeon Results. Am J Ophthalmol 2020; 220:191-202. [PMID: 32707206 DOI: 10.1016/j.ajo.2020.07.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare the clinical outcomes in femtosecond laser-assisted deep anterior lamellar keratoplasty (F-DALK) to manual non-laser deep anterior lamellar keratoplasty (M-DALK) for keratoconus in a multi-surgeon public healthcare setting. DESIGN Single-center, comparative, retrospective interventional case series. METHODS Population: Consecutive cases of keratoconus treated with big-bubble F-DALK from August 1, 2015, to September 1, 2018 and big-bubble M-DALK from September 1, 2012, to September 30, 2016. SETTING Moorfields Eye Hospital, London. OBSERVATIONS Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived on a customized spreadsheet for analysis. MainOutcomeMeasures: Rate of intraoperative perforation and conversion to penetrating keratoplasty (PK) and the percentage of patients, post removal of sutures (ROS), with corrected distance visual acuity (CDVA) ≥20/40. RESULTS We analyzed 58 eyes of 55 patients who underwent F-DALK and 326 eyes of 309 patients who underwent M-DALK. Intraoperative perforation of Descemet membrane occurred in 15 of 58 (25.9%) F-DALK cases compared to 148 of 326 (45.4%) M-DALK cases (P = .006). Intraoperative conversion to PK was carried out in 2 of 58 (3.4%) F-DALK cases compared to 80 of 326 (24.5%) M-DALK cases (P = .001). Post ROS, 86.5% of F-DALK eyes had a CDVA of ≥20/40 (15 ± 7.3 months after surgery) compared to 83.7% of M-DALK eyes (24.9 ± 10.6 months) (P = .825). CONCLUSION Laser automation of some steps in DALK for keratoconus may reduce the rate of intraoperative Descemet perforation and the conversion to PK in a multi-surgeon setting.
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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: 0.4] [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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Sahay P, Stevenson LJ, Agarwal T, Sharma B, Sharma N, Vajpayee RB. Shaped corneal transplantation surgery. Br J Ophthalmol 2020; 105:9-16. [PMID: 32217546 DOI: 10.1136/bjophthalmol-2019-315754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/22/2020] [Accepted: 03/11/2020] [Indexed: 11/04/2022]
Abstract
Since its inception in 1905, keratoplasty techniques have continuously evolved. Shaped keratoplasty procedures have allowed corneal surgeons to use complex graft-host junctions and non-circular graft designs to optimise wound strength and healing, facilitate early suture removal and expedite visual rehabilitation. While this was initially limited to penetrating procedures, shaped lamellar keratoplasty techniques have since emerged. Furthermore, the arrival of femtosecond laser has dramatically increased the range of graft designs available to surgeons, due to the technology's ability to precisely cut complex wound edges. This review describes the broad range of shaped keratoplasty grafts currently available and elaborates on their respective advantages and disadvantages in relation to conventional keratoplasty.
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Affiliation(s)
- Pranita Sahay
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | | | - Tushar Agarwal
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Bhavana Sharma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Namrata Sharma
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia .,University of Melbourne, Parkville, Victoria, Australia.,Vision Eye Institute, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW A survey of the recent literature of deep anterior lamellar keratoplasty using femtosecond laser technology. RECENT FINDINGS There are several recent reports in the literature assessing technique and outcomes of deep anterior lamellar keratoplasty done with a femtosecond laser trephination. Most of these reports are laboratory studies and small case series with short-term outcomes. The laser technology is expensive and may not produce better results than conventional manual techniques. However, there are several theoretical advantages to femtosecond laser incisions in deep anterior lamellar keratoplasty that should be explored, including possible increased success of Descemet's membrane separation from stroma during surgery as well as postsurgical astigmatism benefits, earlier suture removal, and increased wound strength and healing. SUMMARY Femtosecond laser trephination in the setting of DALK may improve the technique by decreasing the number of descemet's membrane ruptures and improving short-term and long-term outcomes as compared with manual techniques. However, there is no consensus on a standardized approach for wound design or postoperative management. The literature would benefit from a prospective randomized controlled trial.
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Abstract
Corneal blindness is one of the major causes of reversible blindness, which can be managed with transplantation of a healthy donor cornea. It is the most successful organ transplantation in the human body as cornea is devoid of vasculature, minimizing the risk of graft rejection. The first successful transplant was performed by Zirm, and since then, corneal transplantation has seen significant evolution. It has been possible because of the relentless efforts by researchers and the increase in knowledge about corneal anatomy, improvement in instruments and advancements in technology. Keratoplasty has come a long way since the initial surgeries wherein the whole cornea was replaced to the present day where only the selective diseased layer can be replaced. These newer procedures maintain structural integrity and avoid catastrophic complications associated with open globe surgery. Corneal transplantation procedures are broadly classified as full-thickness penetrating keratoplasty and partial lamellar corneal surgeries which include anterior lamellar keratoplasty [sperficial anterior lamellar keratoplasty (SALK), automated lamellar therapeutic keratoplasty (ALTK) and deep anterior lamellar keratoplasty (DALK)] and posterior lamellar keratoplasty [Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK)] broadly.
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Affiliation(s)
- Rashmi Singh
- Cornea, Cataract & Refractive Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Noopur Gupta
- Cornea, Cataract & Refractive Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - M. Vanathi
- Cornea, Cataract & Refractive Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Radhika Tandon
- Cornea, Cataract & Refractive Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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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: 2.0] [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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Garcia-Ferrer FJ, Akpek EK, Amescua G, Farid M, Lin A, Rhee MK, Varu DM, Musch DC, Mah FS, Dunn SP. Corneal Ectasia Preferred Practice Pattern®. Ophthalmology 2019; 126:P170-P215. [DOI: 10.1016/j.ophtha.2018.10.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023] Open
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Farid M, Rhee MK, Akpek EK, Amescua G, Garcia-Ferrer FJ, Lin A, Varu DM, Musch DC, Mah FS, Dunn SP. Corneal Edema and Opacification Preferred Practice Pattern®. Ophthalmology 2018; 126:P216-P285. [PMID: 30366795 DOI: 10.1016/j.ophtha.2018.10.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Marjan Farid
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California, Irvine, California
| | - Michelle K Rhee
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Esen K Akpek
- The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Guillermo Amescua
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Amy Lin
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
| | | | - David C Musch
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Francis S Mah
- Departments of Cornea and External Diseases, Scripps Clinic Torrey Pines, La Jolla, California
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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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Nanavaty MA, Vijjan KS, Yvon C. Deep anterior lamellar keratoplasty: A surgeon's guide. J Curr Ophthalmol 2018; 30:297-310. [PMID: 30555961 PMCID: PMC6276733 DOI: 10.1016/j.joco.2018.06.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 05/27/2018] [Accepted: 06/09/2018] [Indexed: 12/14/2022] Open
Abstract
Purpose To review and highlight important practical aspects of deep anterior lamellar keratoplasty (DALK) surgery and provide some useful tips for surgeons wishing to convert to this procedure from the conventional penetrating keratoplasty (PK) technique. Methods In this narrative review, the procedure of DALK is described in detail. Important pre, intra, and postoperative considerations are discussed with illustrative examples for better understanding. A comprehensive literature review was conducted in PubMed/Medline from January 1995 to July 2017 to identify original studies in English language regarding DALK. The primary endpoint of this review was the narrative description of surgical steps for DALK, its pitfalls, and management of common intraoperative complications. Results A standard DALK procedure can be successfully performed taking into consideration factors such as age, ophthalmic co-morbidities, status of the crystalline lens, retina, and intraocular pressure. Careful trephination and dissection of the host cornea employing appropriate technique (such as big bubble technique, manual dissection, visco-dissection, etc.) suitable for the specific case is important to achieve good postoperative outcomes. Prompt identification of intraoperative complications such as double bubble, micro and macroperforations, etc. are vital to change the management strategies. Conclusion Although there is a steep learning curve for DALK procedure, considering details and having insight into the management of intraoperative issues facilitates learning and reduces complication rates.
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Affiliation(s)
- Mayank A Nanavaty
- Sussex Eye Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Kanwaldeep Singh Vijjan
- Sussex Eye Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Camille Yvon
- Sussex Eye Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom
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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: 0.5] [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: 12] [Impact Index Per Article: 1.5] [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: 1.0] [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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Espandar L, Mandell JB, Niknam S. Femtosecond laser-assisted decagonal deep anterior lamellar keratoplasty. Can J Ophthalmol 2016; 51:67-70. [DOI: 10.1016/j.jcjo.2015.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 12/05/2015] [Accepted: 12/07/2015] [Indexed: 11/29/2022]
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Fung SSM, Aiello F, Maurino V. Outcomes of femtosecond laser-assisted mushroom-configuration keratoplasty in advanced keratoconus. Eye (Lond) 2016; 30:553-61. [PMID: 26795410 DOI: 10.1038/eye.2015.273] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/13/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the long-term outcomes after femtosecond laser (FSL)-assisted mushroom-configuration keratoplasty in advanced keratoconus. PATIENTS AND METHODS Thirteen eyes with Amsler-Krumeich stage IV keratoconus underwent FSL-assisted mushroom-configuration penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) at a tertiary referral centre. Preoperative risk factors included low orneal thickness, high keratometry measurements, previous hydrops, and central stromal scarring. Main outcome measures were visual acuity and refractive outcome. RESULTS The median follow-up was 33 months (range: 4-43). Preoperatively, the mean corrected distance visual acuity (CDVA) was 1.22±0.47 LogMAR (range: 0.5-1.9 LogMAR), mean minimum corneal thickness was 282±100.8 μm (range: 147-478 μm), and mean average keratometric (K) value was 63.4±7.63 dioptre (D; range: 57.0-75.7 D). Four patients underwent PKP and nine underwent DALK (two converted to PKP). Five patients subsequently underwent a modified arcuate mushroom interface dissection (AMID) procedure for astigmatic correction. At the final follow-up, the mean CDVA was 0.05±0.13 LogMAR (range: -0.10 to 0.20 LogMAR), mean spherical equivalent was -3.21±3.21D, mean cylindrical refractive error was 3.23±2.20 D, and mean average K was 43.1±1.53 D. Complications included early graft dehiscence, corneal vascularisation, stromal rejection, and sclerokeratitis. Sutures were completely removed at the mean 18.4 months for PKP and 9.1 months for DALK postoperatively. CONCLUSION FSL-assisted mushroom-configuration keratoplasty is feasible and safe in patients with stage IV keratoconus. AMID could further enhance the refractive outcome safely.
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Affiliation(s)
- S S M Fung
- Cornea and External Disease Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - F Aiello
- Cornea and External Disease Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Department of Experimental Medicine and Surgery, Ophthalmology Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - V Maurino
- Cornea and External Disease Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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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: 0.5] [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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Wan KHN, Yiu EPF, Young AL. Corneal transplantation: Beyond the horizon. World J Ophthalmol 2015; 5:36-44. [DOI: 10.5318/wjo.v5.i2.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/04/2015] [Accepted: 04/02/2015] [Indexed: 02/06/2023] Open
Abstract
Evolving techniques in keratoplasty have undoubtedly led to thinner corneal grafts. These newer iterations of keratoplasty aim to reduce graft rejections, improve visual acuity and visual rehabilitation. Each technique poses its own advantages and disadvantages; the surgeon should select patients suitable for a particular technique while accounting for their surgical competency given the learning curve associated with these newer techniques. Alternatives to corneal transplant may have a role in addressing the shortages of corneal graft, these bioengineered material and medical treatment still need further studies to demonstrate its clinical applicability.
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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: 1.3] [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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Keane M, Coster D, Ziaei M, Williams K, Cochrane Eyes and Vision Group. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for treating keratoconus. Cochrane Database Syst Rev 2014; 2014:CD009700. [PMID: 25055058 PMCID: PMC10714035 DOI: 10.1002/14651858.cd009700.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Keratoconus is an ectatic (weakening) disease of the cornea, which is the clear surface at the front of the eye. Approximately 10% to 15% of patients diagnosed with keratoconus require corneal transplantation. This may be full-thickness (penetrating) or partial-thickness (lamellar). OBJECTIVES To compare visual outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty for keratoconus, and to compare additional outcomes relating to factors which may contribute to poor visual outcomes (e.g. astigmatism, graft rejection and failure). SEARCH METHODS We searched a number of electronic databases including CENTRAL, PubMed and EMBASE without using any date or language restrictions. We last searched the electronic databases on 31 October 2013. We also handsearched the proceedings of several international ophthalmic conferences. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing the outcomes of DALK and penetrating keratoplasty in the treatment of keratoconus. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data independently. For dichotomous data (graft failure, rejection, achievement of functional vision) results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs). For continuous data (postoperative best corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), keratometric astigmatism and spherical equivalent) results were expressed as mean differences (MDs) and 95% CIs. MAIN RESULTS We identified two completed studies, with a total of 111 participants (n = 30 and n = 81), both conducted in Iran, that met our inclusion criteria. Participants had moderate to severe keratoconus pre-operatively and were randomly allocated to receive either DALK or penetrating keratoplasty. Only one eye of each participant was treated as part of the trials. The smaller study had 12 month follow-up data for all participants. For the larger study, four DALK surgeries had to be abandoned due to technical failure and visual and refractive outcomes were not measured in these participants. Follow-up length for the remaining 77 participants ranged from 6.8 to 36.4 months, with all 77 followed for at least three months post-suture removal. Details of the randomisation procedure were unavailable for the smaller study and so sensitivity analyses were conducted to determine if the results from this study had affected the overall results of the review.Neither of the included studies reported a difference between groups on any of the measures of post-graft visual achievement, keratometric astigmatism or spherical equivalent. A single case of graft failure in a penetrating keratoplasty was reported. No postoperative graft failures were reported in the DALK group of either study.Instances of graft rejection were reported in both groups, in both studies. The majority of these cases were successfully treated with steroids. The data, which related to all cases in each study - given that the four cases that did not go ahead as planned had already technically failed without presence of rejection - showed that rejection was less likely to occur in DALK (odds ratio (OR): 0.33, 95% confidence interval (CI) 0.14 to 0.81, GRADE rating: moderate).Results of the sensitivity analysis indicated that inclusion of the Razmju 2011 study did not bias the results with regards to rejection episodes. While sensitivity analysis showed altered results with regards to failure rates, the data available from the Javadi 2010 study alone had a very wide 95% CI, suggesting an imprecise estimate. Therefore, even after removal of the Razmju 2011 data, it is still difficult to draw conclusions regarding superiority of one technique over another with regards to graft failure.DALK was unable to be completed as planned in four cases and in a further three cases, complications during dissection required further intervention. Other adverse events, of varying severity, were reported in both intervention groups with similar frequency. For both types of surgery, these included postoperative astigmatism, steroid induced ocular hypertension and persistent epithelial defects. In recipients of DALK, one participant had interface neovascularisation (a proliferation of blood vessels where the host and donor cornea come together) and one had wrinkling of Descemet's membrane, the basement membrane separating the corneal stroma from the corneal endothelium. In the penetrating keratoplasty groups, one participant required graft resuturing and one had an atonic pupil, a condition in which the pupil dilates and is non-reactive.Overall, the quality of the evidence was rated as very low to moderate, with methodological limitations, incomplete data analysis and imprecision of findings, as well as high risk of bias in several areas for both studies. AUTHORS' CONCLUSIONS We found no evidence to support a difference in outcomes with regards to BCVA at three months post-graft or at any of the other time points analysed (GRADE rating: very low). We also found no evidence of a difference in outcomes with regards to graft survival, final UCVA or keratometric outcomes. We found some evidence that rejection is more likely to occur following penetrating keratoplasty than DALK (GRADE rating: moderate). The small number of studies included in the review and methodological issues relating to the two, mean that the overall quality of the evidence in this review is low. There is currently insufficient evidence to determine which technique may offer better overall outcomes - final visual acuity and time to attain this, keratometric stabilisation, risk of rejection or failure, or both, and risk of other adverse events - for patients with keratoconus. Large randomised trials comparing the outcomes of penetrating keratoplasty and DALK in the treatment of keratoconus are needed.
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Affiliation(s)
- Miriam Keane
- Flinders UniversityDepartment of OphthalmologyLevel 3 Flinders Medical CentreBedford ParkAdelaideAustraliaSA 5042
| | - Douglas Coster
- Flinders UniversityDepartment of OphthalmologyLevel 3 Flinders Medical CentreBedford ParkAdelaideAustraliaSA 5042
| | - Mohammed Ziaei
- Moorfields Eye Hospital NHS Foundation Trust162 City RoadLondonUKEC1V 2PD
| | - Keryn Williams
- Flinders UniversityDepartment of OphthalmologyLevel 3 Flinders Medical CentreBedford ParkAdelaideAustraliaSA 5042
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Kymionis GD, Mikropoulos DG, Portaliou DM, Boboridis KG, Voudouragkaki IC, Dragoumis ND, Konstas AGP. New perspectives on lamellar keratoplasty. Adv Ther 2014; 31:494-511. [PMID: 24846543 DOI: 10.1007/s12325-014-0121-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Indexed: 11/28/2022]
Abstract
Lamellar (anterior and posterior) keratoplasty entails the surgical replacement of diseased-only corneal tissue, while healthy host corneal tissue is preserved. Selective keratoplasty offers several advantages in comparison to penetrating keratoplasty such as a lower rate of graft rejection, less endothelial cell loss, faster/superior visual rehabilitation and enhanced resistance to closed injury. The surgical approach of "partial corneal transplantation" may be divided into anterior and posterior: techniques including superficial and deep anterior lamellar keratoplasty (SALK and DALK, respectively) and endothelial keratoplasty as well as Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK). These novel surgical procedures are rapidly becoming the preferred therapy option for specific corneal dysfunctions involving the corneal stroma (SALK, DALK), or corneal endothelium (DSAEK, DMEK). During the past decade, the continuing advancement of surgical techniques and the development of innovative surgical instruments have significantly enhanced corneal transplantation. Lamellar keratoplasty techniques facilitate corneal surgery, provide patients with superior outcomes and can successfully restore vision in corneal-related blindness. Nevertheless, more long-term evidence is needed to better evaluate these promising new techniques.
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Affiliation(s)
- George D Kymionis
- Vardinoyiannion Eye Institute of Crete (VEIC), Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
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Baradaran-Rafii A, Hasani H. Different techniques for performing DALK: are they making a real difference? Br J Ophthalmol 2014; 98:1311-2. [PMID: 24682177 DOI: 10.1136/bjophthalmol-2013-304407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Hamidreza Hasani
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Daya SM, Nanavaty MA, Espinosa-Lagana MM. Translenticular hydrodissection, lens fragmentation, and influence on ultrasound power in femtosecond laser–assisted cataract surgery and refractive lens exchange. J Cataract Refract Surg 2014; 40:37-43. [DOI: 10.1016/j.jcrs.2013.07.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 07/22/2013] [Accepted: 07/22/2013] [Indexed: 10/26/2022]
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Shehadeh-Mashor R, Chan CC, Bahar I, Lichtinger A, Yeung SN, Rootman DS. Comparison between femtosecond laser mushroom configuration and manual trephine straight-edge configuration deep anterior lamellar keratoplasty. Br J Ophthalmol 2013; 98:35-9. [PMID: 24158841 DOI: 10.1136/bjophthalmol-2013-303737] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AIM To compare outcomes and complications of femtosecond laser (FSL) mushroom configuration and manual trephine (MT) straight-edge configuration deep anterior lamellar keratoplasty (DALK). METHODS A cohort of 19 consecutive eyes that underwent FSL DALK was compared with 19 consecutive eyes that underwent MT DALK. Surgery was performed for eyes with keratoconus, corneal ectasia and scarring. Patient demographics, best-corrected visual acuities (BCVAs), refraction and complications were compared. RESULTS Groups were comparable for age, gender and preoperative BCVA. Rates of intraoperative and postoperative complications were low and comparable between the groups. These included intraoperative Descemet's membrane (DM) perforation which did not require conversion to penetrating keratoplasty; stromal rejection successfully treated with topical steroids; postoperative DM detachment; delayed epithelial healing and increased intraocular pressure which resolved with topical anti-glaucoma drops. At 3 months, the mean BCVA was significantly better in the FSL group compared with the MT group (p=0.00002). At 6 months and 1 year, there was no significant difference between mean BCVA between the two groups. Mean spherical equivalent, cylindrical astigmatism and keratometric cylinder preoperatively and at 3, 6 and 12 months postoperatively were similar between the two groups. CONCLUSIONS FSL or trephine DALK are viable options for keratoconus, ectasia and corneal scars. Earlier visual recovery occurs with FSL mushroom configuration compared with MT straight-edge DALK.
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Lamellar keratoplasty: a literature review. J Ophthalmol 2013; 2013:894319. [PMID: 24223301 PMCID: PMC3816057 DOI: 10.1155/2013/894319] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 08/01/2013] [Accepted: 08/19/2013] [Indexed: 12/02/2022] Open
Abstract
The concept of lamellar keratoplasty (LK) is not new. However, newer forms of lamellar keratoplasty techniques have emerged in the last decade or so revolving around the concept of targeted replacement of diseased corneal layers. These include anterior lamellar keratoplasty (ALK) techniques that aim to selectively replace diseased corneal stroma and endothelial keratoplasty techniques aiming to replaced damaged endothelium in endothelial disorders. Recent improvements in surgical instruments and introduction of new techniques as well as inherent advantages such as preservation of globe integrity and decreased graft rejection have resulted in the reintroduction of LK as an acceptable alternative to conventional PK. In this review, indications, benefits, limitations, and outcomes of various anterior and posterior lamellar keratoplasty techniques are discussed.
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Long-Term Outcomes of Femtosecond Laser–Assisted Mushroom Configuration Deep Anterior Lamellar Keratoplasty. Cornea 2013; 32:390-5. [DOI: 10.1097/ico.0b013e318254a4e4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Arenas E, Esquenazi S, Anwar M, Terry M. Lamellar corneal transplantation. Surv Ophthalmol 2013; 57:510-29. [PMID: 23068974 DOI: 10.1016/j.survophthal.2012.01.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/24/2012] [Accepted: 01/27/2012] [Indexed: 11/29/2022]
Abstract
Penetrating keratoplasty (PK) has been the gold standard for the surgical treatment of most corneal pathologies; lamellar keratoplasty that only replaces the diseased corneal layers has recently evolved as an alternative, however. Innovations in surgical technique and instrumentation provide visual outcomes comparable to PK. We review the indications and outcomes of various techniques of anterior lamellar surgery developed to treat stromal disorders. Similarly, we discuss posterior lamellar keratoplasty techniques such as Descemet stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty. Posterior lamellar keratoplasty provides faster visual rehabilitation than PK in cases of Fuchs endothelial dystrophy and pseudophakic bullous keratopathy. In addition, for medically unresponsive infectious keratitis, therapeutic anterior lamellar keratoplasty yields similar graft survival to PK without an increased risk of disease recurrence.
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Lee WB, Meinecke E, Varnum B. The evolution of eye banking and corneal transplantation: a symbiotic relationship. Int Ophthalmol Clin 2013; 53:115-129. [PMID: 23470594 DOI: 10.1097/iio.0b013e31827823c5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Abstract
OBJECTIVES To develop a dual laser-assisted lamellar anterior keratoplasty (LALAK) technique, using excimer and femtosecond lasers to perform surgery on eye bank eyes. METHODS First, we compared corneal stromal surfaces produced by (1) deep excimer ablation, (2) femtosecond lamellar cuts, and (3) manual dissection and evaluated the effect of excimer laser smoothing with fluid masking on each surface. Masked observers graded scanning electron microscopy images on a 5-point roughness scale. Then, we performed a 6-mm diameter excimer laser phototherapeutic keratectomy ablation to a residual bed thickness of 200 μm, followed by laser smoothing. We used the femtosecond laser to cut donors in a modified top hat design with a thin tapered brim, which fitted into a manually dissected circumferential pocket at the base of the recipient bed. Fourier domain optical coherence tomography was used to measure corneal pachymetry and evaluate graft fit. RESULTS Deep excimer ablation with smoothing (n = 4) produced a significantly (P < 0.05) smoother surface (grade = 3.5) than deep excimer alone (n = 4, grade = 3.8) or manual dissection with (n = 1, grade = 3.8) and without smoothing (n = 1, grade = 4.8). Deep femtosecond cuts (n = 2) produced macroscopic concentric ridges on the stromal surface. Experimental LALAK was performed on 4 recipients prepared by deep excimer ablation and 4 donors cut with the femtosecond laser. After suturing, good peripheral graft-host match was observed on Fourier domain optical coherence tomography imaging. CONCLUSION These preliminary studies show that the LALAK technique permits improved interface smoothness and graft edge matching. Clinical trials are needed to determine whether these improvements can translate to better vision.
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Internal view of the effects of the big-bubble technique during experimental deep anterior lamellar keratoplasty. Cornea 2012; 31:1489-92. [PMID: 22968359 DOI: 10.1097/ico.0b013e31825d5853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine how the air bubble dissects Descemet membrane from the inside during experimental deep lamellar anterior keratoplasty. METHODS In this experimental study, 4 corneas from enucleated human eyes were dissected and placed in an artificial anterior chamber. Air was injected through a 27-gauge needle into the midperiphery without previous trephination until a big bubble formed. The results were photographed from the inside. RESULTS The edge of the air dissection was viewed clearly. The dissection was not uniform; one side was dissected more than the other. Descemet membrane and the stroma may still have been attached. The results provided a clue about why perforation frequently occurs when dissecting the anterior lamella in the periphery. CONCLUSION As much air as possible should be injected. Premature cessation of the injection of air can result in irregular dissection by all edges of the bubble or an incomplete bubble.
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Glasser DB. Is the femtosecond laser worth it? Am J Ophthalmol 2012; 154:217-8. [PMID: 22813446 DOI: 10.1016/j.ajo.2012.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 03/13/2012] [Accepted: 03/13/2012] [Indexed: 11/15/2022]
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A Novel Mutation of the Decorin Gene Identified in a Korean Family With Congenital Hereditary Stromal Dystrophy. Cornea 2011; 30:1473-7. [DOI: 10.1097/ico.0b013e3182137788] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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