Deep Anterior Lamellar Keratoplasty for Keratoconus: Multisurgeon Results

Abstract

To examine clinical outcomes in deep anterior lamellar keratoplasty (DALK) for keratoconus using contemporary techniques in a multisurgeon public healthcare setting. Consecutive, retrospective case series. Setting: Moorfields Eye Hospital, London, United Kingdom. Consecutive cases of keratoconus treated with non-laser assisted DALK from September 1, 2012, to September 31, 2016. Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived for analysis. Graft failure rate and percentage of patients with corrected distance visual acuity (CDVA) ≥20/40 within 1 year of surgery and at final review after suture removal. Three hundred fifty-seven eyes of 338 patients undergoing DALK (91.3% big-bubble technique attempted) were analyzed. A total of 4.2% (95% confidence interval [CI] 2.4%-6.8%) of corneal transplants had failed within the follow-up period (21.8 ± 11.4months), and 75.9% of eyes had CDVA ≥20/40 within 1 year of surgery, rising to 81% after suture removal. Forty-two primary surgeons (31 trainees) participated. Intraoperative perforation of Descemet membrane occurred in 45.4% of eyes. A total of 24.1% were converted to penetrating keratoplasty (PK) intraoperatively. Conversion to PK increased the risk of transplant rejection (P= .026; odds ratio [OR] 1.94; 95% CI 1.1-3.5) and secondary glaucoma (P= .016; OR 4.0; 95% CI 1.3-12.4). Transplant rejection increased the risk of graft failure both overall (P= .017; OR= 3.9; 95% CI 1.4-11.0) and when cases converted to PK were excluded (P= .028; OR= 3.35; 95% CI 1.1-9.9). DALK for keratoconus achieves early results similar to those published for PK in a multisurgeon setting. Conservative management of intraoperative Descemet membrane perforation, where possible, may be safer than conversion to PK.