Deep Anterior Lamellar Keratoplasty After Descemet Stripping Automated Endothelial Keratoplasty

Abstract

To report the indications and long-term outcomes of deep anterior lamellar keratoplasty (DALK) performed after Descemet stripping automated endothelial keratoplasty (DSAEK) in cases of visually significant stromal opacities. Retrospective, interventional, consecutive case series. Setting: Private hospital. Thirteen eyes that underwent DALK after DSAEK at our institution. Indications for DALK after DSAEKincluded both stromal opacities persisting after DSAEK and stromal opacities occurring secondarily in post-DSAEK corneas. DALK was always performed in a standardized fashion including exchange of a disc of full-thickness recipient cornea (up to the DSAEK stromal surface),7.0mm in diameter, with a donor lamella obtained by microkeratome-assisted dissection, punched to 7.0mm and sutured into place with a double running 10-0 nylon suture. Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density (ECD). Mean follow-up was 26 ± 18months (range= 6-60months). Indications for DSAEK were full-thickness graft failure (n= 8), DSAEK graft failure (n= 3), and pseudophakic bullous keratopathy (n= 2). Indications for subsequent DALK were persisting stromal opacity (n= 9) and stromal opacities newly occurred after DSAEK as a result of HSV keratitis (n= 2) or interface infection (n= 2). After complete suture removal, mean BSCVA was 20/28 (0.14 ± 0.8 logMAR) in eyes without ocular comorbidities affecting visual acuity (n= 7), while refractive astigmatism was within 4diopter (D) in all but 1 eye (average= 3.2 ± 1.4 D). No intraoperative complications were recorded. Performing DALK on DSAEK eliminates the need for open-sky surgery, achieving visual results comparable to those of penetrating keratoplasty, while sparing a healthy endothelial graft.