Deep Anterior Lamellar Keratoplasty Research Articles

Large-diameter deep anterior lamellar keratoplasty: A narrative review.

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.

Anterior chamber phakic lens implantation after deep anterior lamellar keratoplasty. Retrospective cohort with 24‐month follow‐up

Aims/Purpose: To report the outcome of correction of high myopia with anterior chamber phakic intraocular lenses (IOLs) implantation after deep anterior lamellar keratoplasty (DALK).Methods: Retrospective study with 7 eyes of patients who underwent DALK. The main variables measured were corrected visual acuity (CVA) and uncorrected visual acuity (UCVA), spherical equivalent, and endothelial cell density (ECD). Follow‐up was performed up to 24 months after the lens implant.Results: The spherical equivalent (SE) recorded a mean of −14.16 (± 3.50) before the lens implant and −0.30 (±0.93) after the implant, with a mean difference of 13.85 (10.25 to 13.85) and a p‐value of <0.001. The mean of uncorrected visual acuity (UCVA) before the lens was 1.82 (±0.63), 6 months after lens implant was 0.22 (±0.07), and after 24 months, 0.30 (±0.14) with a p‐value of 0.001. Among patients, 85.71% had a UCVA equal to or better than 0.3 logMAR and 42.85% had a UCVA of 0.2 logMAR vs. 0% preoperatively. 71.42% of the patients had residual ametropia within ±1.00 D. The mean corrected visual acuity (CVA) was 0.31 (±0.06) before lens implantation, 0.12 (±0.04) 6 months post‐ implantation and 0.14 (±0.05) 24 months post‐implantation. All patients had improvement of UCVA of at least 10 lines of vision (range 10 to 14); at 6 months, 71.42% of patients had a gain of at least 2 lines of vision in CVA and at 24 months only one patient had a decrease in UCVA. The mean difference in ECD was 68.71 (95% CI 11.97 to 125.44), corresponding to a loss of 1.26% of cells per year.Conclusions: Phakic IOLs are an effective and stable procedure for management of high myopia after DALK, demonstrating stable safety and efficacy rates up to 24 months. The known risk of endothelial loss should be closely monitored, as such loss is higher compared to eyes with phakic IOL implants without DALK.

Modern techniques and features of selective keratoplasty

Selective keratoplasty involves replacing the affected layers of the cornea with similar donor tissue. In case of pathological changes in the middle and posterior stroma, deep anterior lamellar keratoplasty (DALK) is performed. Chronic corneal edema caused by endothelial dysfunction is an indication for endothelial keratoplasty - Descemet membrane endothelial keratoplasty (DMEK) or Descemet Stripping Endothelial Keratoplasty (DSAEK). Compared to penetrating keratoplasty (PK), these operations are characterized by a low risk of damage to intraocular structures and a relatively short rehabilitation period. Complications of selective keratoplasty include the formation of a false chamber between the lamellar graft and the recipient's cornea, ocular hypertension during anterior chamber air tamponade. Persistent epithelial defect can be a sign of primary graft failure in DALK, DSAEK and DMEK. Selective keratoplasty is characterized by a lower incidence of immune rejection than PK. In some cases, DALK can be complicated by corneal changes related to suture fixation of the graft. Long-term postoperative use of topical glucocorticoids can cause ocular hypertension and cataracts.

Keratoconus: imaging modalities and management.

Keratoconus (KCN) is characterized by gradual thinning and steepening of the cornea, which can lead to significant vision problems owing to high astigmatism, corneal scarring, or even corneal perforation. The detection of KCN in its early stages is crucial for effective treatment. In this review, we describe current advances in the diagnosis and treatment of KCN. This narrative review focuses on recent advancements in the diagnosis and treatment of KCN, especially evolving approaches and strategies. To ensure the inclusion of the most recent literature, relevant publications discussing advanced imaging techniques and treatment options for KCN were extensively gathered from the PubMed/MEDLINE and Google Scholar databases. The following index terms and keywords were used for the online search: keratoconus, diagnosis of keratoconus, advances in the diagnosis of keratoconus, topography or tomography, anterior segment optical coherence tomography, treatment of keratoconus, advances in the treatment of keratoconus, collagen crosslinking, intrastromal ring, keratoplasty, and new techniques in keratoconus. Various screening methods such as corneal topography, tomography, anterior segment optical coherence tomography, and assessment of corneal biomechanics have been developed to identify KCN in its early stages. After diagnosis, KCN management focuses on preventing disease progression. Corneal collagen crosslinking is a minimally invasive treatment that can slow or stop the progression of the condition. Recent research has also explored the use of copper sulfate eye drops (IVMED-80) as a noninvasive treatment to prevent the progression of KCN. Current treatment options for visual improvement include scleral lenses, intracorneal ring segments, corneal allogeneic intrastromal ring segments, and deep anterior lamellar keratoplasty. Recently, novel alternative procedures, such as isolated Bowman layer transplantation, either as a corneal stromal inlay or onlay, have demonstrated encouraging outcomes. Artificial intelligence has gained acceptance for providing best practices for the diagnosis and management of KCN, and the science of its application is contentiously debated; however, it may not have been sufficiently developed. Early detection and advancements in screening methods using current imaging modalities have improved diagnosis of KCN. Improvement in the accuracy of current screening or diagnostic tests and comparison of their validities are achievable by well-designed, large-scale, prospective studies. The safety and effectiveness of emerging treatments for KCN are currently being investigated. There is an ongoing need for studies to track progress and evaluate clinicians' knowledge and practices in treating patients with KCN. Artificial intelligence capabilities in management approach considering the currently available imaging modalities and treatment options would best benefit the patient.

Периферические язвы роговицы в ассоциации с ревматической патологией

Background: peripheral ulcerative keratitis (PUK) is a polyetiological disease. The pathogenesis of PUK is attributed to a combination of factors, including the anatomy of the peripheral cornea, the activation of autoimmune reactions, and the corneal destruction caused by autoan- tibodies and matrix metalloproteinases. Aim: to describe the clinical symptoms of PUK, its association with rheumatic diseases (RD), its course, and the efficacy of treatment options. Patients and Methods: а total of 32 patients (9 men and 23 women, mean age 59.3±9.4 years) with PUK associated with RD were under surveillance. The diagnosis was established based on the results of eye examinations, tear production test, and multidisciplinary examination. Treatment was performed in an outpatient or inpatient setting based on the severity of corneal lesions. Results: the most common association between PUK and RD was established with rheumatoid arthritis (56.2%). Clinical hallmarks of PUK included mild infiltration and perifocal corneal edema, accompanied by the appearance of an oval or sickle-shaped epithelial and stromal defect 2–4 mm from the limbus. Additionally, rapid corneal lysis and perforation (18.7%) and association with perilimbal vasculitis and scleritis (31.2%) were observed. Bilateral corneal lesions were observed in 56.2%. Tear production, as measured by Schirmer's test, was 6±2 mm, while tear film stability was 2±1 mm. Conservative management was found to be effective in 59.4% (outpatient treatment in 40.6% and inpatient treatment in 18.7%). Surgical interventions were performed for emergent indications, including tectonic keratoplasty (21.9%) and deep anterior lamellar keratoplasty (15.6%). Conclusion: PUK represents a severe clinical manifestation of visual disorders in RD. Treatment for PUK involves local and systemic steroids in the acute period, basic immunosup-pressive therapy, and, when necessary, keratoplasty. Systemic rheumatological therapy, regular use of tear substitutes and reparative preparations are prescribed to prevent recurrences. KEYWORDS: keratitis, corneal ulcer, limbus, autoimmune diseases, rheumatoid arthritis, keratoplasty. FOR CITATION: Drozdova E.A. Peripheral corneal ulcers in association with rheumatic diseases. Russian Journal of Clinical Ophthalmology. 2024;24(2):88–93 (in Russ.). DOI: 10.32364/2311-7729-2024-24-2-8.

Diamond ophthalmic burr-assisted deep anterior lamellar keratoplasty – Case series

This case series presents a simple technique using the diamond ophthalmic burr (DOB) to perform successful deep anterior lamellar keratoplasty (DALK) in cases where the big-bubble technique is unsuitable or intraoperative Descemet membrane perforation occurs. Five patients underwent DOB-assisted DALK, and postoperative outcomes were evaluated, including best-corrected visual acuity, corneal astigmatism, residual host tissue thickness, and postoperative endothelial cell count. Manual corneal lamellar dissection was performed, followed by DOB-assisted pre-Descemet layer polishing and donor graft attachment using 16 (10-0) Monofilament Nylon sutures. The postoperative visual acuity significantly improved. DOB-assisted DALK is a viable alternative.

Deep Anterior Lamellar Keratoplasty Using Dehydrated versus Standard Organ Culture-Stored Donor Corneas: Prospective Randomized Trial

PurposeTo compare the outcomes of deep anterior lamellar keratoplasty (DALK) using dehydrated versus standard organ culture stored donor corneas for eyes with keratoconus. DesignProspective, randomized, single-center trial conducted in Italy ParticipantsAdult patients with keratoconus (≥ 18 years old) with keratoconus scheduled for an elective DALK MethodsCases with successful type 1 bubble pneumatic dissection using standard DALK technique were intraoperatively randomized to receive either dehydrated (n=30) or standard organ culture stored donor corneas (n=30). Main Outcome MeasuresThe primary study outcome was best spectacle-corrected visual acuity (BSCVA) 12 months after surgery. Secondary outcomes were refractive astigmatism (RA), endothelial cell density (ECD) and complication rates. ResultsPostoperative logMAR BSCVA did not significantly differ between groups at both time points (mean difference at 6 months = 0.030 [95%CI: -0.53-0.10] p = 0.471) and at 12 months = -0.013 [95%CI: -0.10-0.08] p = 0.764). No significant differences between groups were observed in terms of postoperative RA and ECD at all time points. In the first 3 days after DALK, an epithelial defect was present in 10 cases (33%) of the organ culture cornea group and in 29 cases (97%) of the dehydrated cornea group. Complete re-epithelialization was achieved by day 7 in all cases (100%) of both groups. ConclusionsThe study provides evidence that the use of dehydrated corneas is non-inferior to the use of standard organ culture donor corneas for DALK. Corneal tissue dehydration represents a viable solution that can allow long-term cornea preservation and avoid wastage of unused corneas.

Deep Anterior Lamellar Keratoplasty-Treated Keratoconic Eyes With Descemet Membrane Rupture.

The aim of this study was to evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) and compare it with penetrating keratoplasty (PKP) in keratoconic eyes with Descemet membrane (DM) rupture. In this comparative retrospective case series, 33 keratoconic eyes with a history of hydrops underwent DALK and 27 received PKP. Baseline and postoperative visual acuity, corneal astigmatism, mean keratometry, endothelial cell density, and complication rates were measured. The median follow-up of patients who underwent DALK was 45 months (range, 4-76 months) and that of patients who underwent PKP was 84 months (range, 4-136 months). Both procedures had comparable postoperative visual acuity, astigmatism, and mean keratometry. Significantly higher endothelial cell densities were observed in DALK than in PKP at 2, 3, and 5 years postsurgery (2043 ± 767 vs. 1165 ± 683 cell/mm 2 , P = 0.007, n = 12 in both groups at 2 years). Intra-DALK, 15 perforations occurred (44.12%) and 1 (2.94%) was converted to PKP. Graft rejection was diagnosed in 1 (3.03%) DALK procedure versus 8 (29.63%) PKP ( P = 0.008), and other long-term complication rates were equivalent. Kaplan-Meier survival analysis also revealed a higher rejection-free survival rate for the DALK group ( P = 0.012). Subgroup analysis within both groups based on the severity of preoperative DM rupture revealed no significant difference in any major 2-year outcomes. DALK showed similar beneficial visual outcome and safety but significantly better endothelial protection over PKP in eyes with keratoconus and previous hydrops. Therefore, DALK is recommended in posthydrops cases irrespective of the DM rupture severity.

Trends in keratoplasty from central and northern India. Part II: Types of keratoplasty.

To report the types of keratoplasty and analyze trends over a period of two decades in central and northern India. This was a retrospective review of eye bank registries of six tertiary eye care centers located in central and north India from 2005 to 2021. The indications and various keratoplasty procedures were compared between 2005-2012 and 2013-2021 to analyze the trend. A total of 13,223 corneal grafts were performed, of which therapeutic penetrating keratoplasty (TPK) (5719, 43.3%) was the most common procedure, followed by optical penetrating keratoplasty (OPK) (5528, 41.8%), Descemet stripping endothelial keratoplasty (DSEK) (1279, 9.7%), deep anterior lamellar keratoplasty (DALK) (376, 2.8%), Descemet membrane endothelial keratoplasty (DMEK) (215, 1.6%), patch grafts (75, 0.6%), and keratoprostheses (31, 0.2%). Overall, OPK procedures decreased (-14.1%, P < 0.001), but TPK (+3.1%, P < 0.019), DSEK (+7.1%, P < 0.001), and DMEK (+1.9%, P < 0.001) procedures increased. Although there was an increasing trend in the use of DALK (+0.8%, P < 0.083) and keratoprostheses (+0.3%, P = 0.074) procedures, the trends were not statistically significant. In keeping with worldwide trends, an increasing trend in lamellar keratoplasties was observed in central and northern India during the past decade. The trend was significant for DSEK. However, as corneal ulcers and scars were the major indications for keratoplasty, TPK and OPK remained the most common procedures.

Keratoconus in India: Clinical presentation and demographic distribution based on big data analytics.

This paper aims to describe the clinical presentation and demographic distribution of keratoconus (KCN) in India by analyzing the electronic medical records (EMR) of patients presenting at a multitier ophthalmology hospital network. This cross-sectional hospital-based study included the data of 2,384,523 patients presenting between January 2012 and March 2020. Data were collected from an EMR system. Patients with a clinical diagnosis of KCN in at least one eye were included in this study. Univariate analysis was performed to identify the prevalence of KCN. A multiple logistic regression analysis was performed using R software (version 3.5.1), and the odds ratios are reported. Data were obtained for 14,749 (0.62%) patients with 27,703 eyes diagnosed with KCN and used for the analysis. The median age of the patients was 22 (inter-quartile range (IQR): 17-27). In total, 76.64% of adults (odds ratio = 8.77; P = <0.001) were affected the most. The majority of patients were male (61.25%), and bilateral (87.83%) affliction was the most common presentation. A significant proportion of the patients were students (63.98%). Most eyes had mild or no visual impairment (<20/70; 61.42%). Corneal signs included ectasia (41.35%), Fleischer ring (44.52%), prominent corneal nerves (45.75%), corneal scarring (13.60%), Vogts striae (18.97%), and hydrops (0.71%). Only 7.85% showed an association with allergic conjunctivitis. A contact lens clinic assessment was administered to 47.87% of patients. Overall, 10.23% of the eyes affected with KCN underwent a surgical procedure. the most common surgery was collagen cross-linking (8.05%), followed by deep anterior lamellar keratoplasty (1.13%) and penetrating keratoplasty (0.88%). KCN is usually bilateral and predominantly affects males. It commonly presents in the second and third decade of life, and only a tenth of the affected eyes require surgical treatment.

Biomechanical behavior of deep anterior lamellar keratoplasty: a finite element analysis

Deep Anterior Lamellar Keratoplasty (DALK) is a surgical procedure used to restore sight and manage corneal diseases by replacing cloudy corneal tissue with allogeneic normal corneal tissue or artificial corneal material. However, the limited availability and mechanical defects of artificial corneal materials pose challenges in DALK. To predicting postoperative mechanical behavior of Deep Anterior Lamellar Keratoplasty (DALK), a three-dimensional finite element model of the postoperative DALK cornea with suture holes was developed. The postoperative corneal displacement and von Mises (VM) stress changes were also simulated under varying depths of cut (DOC: 0.16-0.26 μm), intraocular pressure (IOP: 12, 15, 18 mmHg), and central corneal thickness (CCT: 420-620 μm). The model indicated that higher IOP and CCT were associated with improved postoperative corneal stability. The postoperative corneal displacement increased from the edge to the center, while the maximum VM stress value occurs at the corneal suture hole. Corneal displacement and VM stress decrease with increasing CCT and decreasing IOP. DOC has a slight effect on corneal displacement and VM stress, with an overall positive relationship. The model has potential application in the preoperative assessment of risk in keratoplasty.

Gamma-irradiated corneas for therapeutic penetrating keratoplasty, anterior lamellar keratoplasty, and sclera for glaucoma valve surgery

Objectives: To report clinical outcomes of gamma-irradiated donor cornea (GIDC) for therapeutic penetrating keratoplasty (TPK), deep anterior lamellar keratoplasty (DALK) and gamma-irradiated donor sclera (GIDS) for glaucoma patch graft (GPG) in glaucoma filtering surgery (GFS) with Ahmed glaucoma valve (AGV). Materials and Methods: A prospective non-randomized, non-comparative, interventional case series of GIDC and GIDS involving 26 patients, of which 20 received GIDC (11 TPK, 9 DALK) and 6 GIDS (6 GPG). Main outcome measures were post-operative tissue characteristics as epithelialization and tissue clarity; and complications including rejection, infection, corneal melt, and other adverse effects. Results: Study included 26 patients, of these 20 received GIDC (11 TPK, 9 DALK) and 6 GIDS (6 GPG). Mean follow up was 8.32 ± 2.31 months. Corneal epithelium healed in 6.2 ± 2.58 days. Graft clarity was achieved in 9 (100%) DALK patients. Only 1 eye (3.8%) had a corneal melt. There were no incidences of rejection or infection in the follow up time. Conclusion: Gamma-irradiated sterilization of donor cornea and sclera is a new innovation to enhance utilization of donor tissue. GIDC is a promising treatment option for TPK and DALK; GIDS for GPG with good epithelialization time and tissue clarity. Gamma irradiation of both donor cornea and sclera achieved adequate sterilization and provided a long shelf life.

Identification and Management of a Central Type 2 Big Bubble in Deep Anterior Lamellar Keratoplasty

Purpose: The purpose of this study was to document a case of central type 2 bubble formation during deep anterior lamellar keratoplasty and discuss its intraoperative management. Methods: A rare case of central type 2 bubble formation with no peripheral extension beyond the trephination mark was documented with operative video and concurrent intraoperative optical coherence tomography imaging. Results: The type 2 bubble was decompressed with a needle intraoperatively, and deep anterior lamellar keratoplasty was successfully performed without perforation of Descemet membrane. Conclusions: Identifying formation of a type 2 bubble during deep anterior lamellar keratoplasty is crucial in avoiding perforation of Descemet membrane. This case shows that the behavior of type 2 bubbles can be different than what has been widely reported. It is hoped that this will aid the surgeon in identifying a type 2 bubble and in properly managing it intraoperatively.

Clinical and Tomographic Outcomes of Intraoperative Descemet’s membrane perforation in Deep Anterior Lamellar Keratoplasty

Clinical and Tomographic Outcomes of Intraoperative Descemet’s membrane perforation in Deep Anterior Lamellar Keratoplasty

Incidence and Clinical Features of Immunologic Rejection After Deep Anterior Lamellar Keratoplasty.

The aim of this study was to investigate the incidence and clinical features of immunologic rejection after deep anterior lamellar keratoplasty (DALK). This study included 411 patients (464 eyes, median age [interquartile range; IQR] 55.8 years [36.1-69.5]) who underwent DALK at Tokyo Dental College between June 1997 and 2021. Of 411 patients, 24 (24 eyes [5.2%], 51.9 years [IQR 31.6-65.4]) developed immunologic rejection. We characterized the clinical features, risk factors associated with immunologic rejection, and prognosis. The interval between DALK and immunologic rejection was 14.5 (range, 5-78) months. Immunologic rejection occurred after cessation/reduction of topical steroid in 9 (47.4%) and suture removal in 4 eyes (21.1%). The postoperative duration of topical steroid use in eyes with immunologic rejection was significantly shorter (10.0 months, [IQR 6.0-14.0]) than those without immunologic rejection (28.3 [IQR 15.8-42.7], P = 0.001). Immunologic rejection manifested as stromal edema in 19 (100.0%), ciliary hyperemia in 17 (89.5%), keratic precipitates in 13 (68.4%), epithelial edema in 13 (68.4%), infiltration in 9 (47.4%), corneal opacity in 4 (21.1%), and Descemet membrane detachment in 2 eyes (10.5%). After treatment, corneal clarity was restored in 17 eyes (89.5%); however, immunologic rejection led to corneal endothelial decompensation in 2 eyes (10.5%). Endothelial cell density decreased from 1795.7 ± 722.6 to 1651.6 ± 655.6 cells/mm 2 after immunologic rejection ( P = 0.074). Post-DALK immunologic rejection was associated with specific clinical triggers such as reduction/cessation of topical steroids or suture removal.

Suture-related complications after deep anterior lamellar keratoplasty for keratoconus.

The purpose of this study is to determine the incidence of suture-related complications, their risk factors, and effects on the clinical outcomes after deep anterior lamellar keratoplasty (DALK) for keratoconus. In this retrospective, comparative, interventional study, the records of consecutive patients with keratoconus who underwent DALK were reviewed for suture-related complications. Univariate analyses were used to identify risk factors for suture complications. We compared groups with and without suture-related complications to evaluate the effects of these complications on clinical outcomes after DALK. Of the 633 DALKs, 438 eyes (69.2%) developed suture complications including loose sutures (32.7%), spontaneous suture rupture (30%), sterile suture abscesses (22.8%), suture tract vascularization (16.4%), suture erosion (10.3%), and suture cheese wiring (6.8%). Vernal keratoconjunctivitis increased the incidence of sterile suture infiltration, premature suture loosening, and suture tract vascularization. Loose suture was observed more commonly in larger graft size, while spontaneous suture rupture was associated with late suture removal. There was no statistically significant difference in postoperative outcomes including visual acuity, refraction, graft rejection, and failure in eyes with and without suture complications. However, suture-related complications were directly associated with sight-threatening ocular morbidities, including graft rejection (39 eyes), ulcer (1 eye), and failure (2 eyes). Suture-related complications frequently occurred after DALK for keratoconus. Ocular surface inflammation, large grafts, and late suture removal increased the risk of suture-related complications. While these complications had no negative impact on clinical outcomes in the majority of cases, some of them led to sight-threatening morbidity, underlining the importance of early diagnosis and treatment.

Long-term outcomes of deep anterior lamellar versus penetrating keratoplasty for keratoconus

AimsTo compare the long-term outcomes of deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in keratoconus.MethodsRetrospective comparative case series (228 DALKs and 274 PKs). A biphasic linear model was...

An unusual case of late spontaneous reattachment of Descemet membrane detachment after deep anterior lamellar keratoplasty: A case report

Deep anterior lamellar keratoplasty (DALK) is a feasible option in children with advanced keratoconus with or without stromal scarring. Descemet membrane detachment (DMD) and formation of double anterior chamber is one of the rare but serious complication of DALK surgery. Various treatment methods like descemetopexy with air, perfluoropropane gas (C3F8), and SF6 (sulfur hexafluoride gas) can be tried. We report a case of spontaneous reattachment of DMD in a pediatric male patient with Descemet membrane microperforation during DALK.

Evaluation of Corneal Topography Changes Following Deep Anterior Lamellar Keratoplasty in Patients with Keratoconus

Background. The aim of this study is to evaluate the morphologic changes of the cornea and anterior chamber by using corneal topography (CT) in patients undergoing deep anterior lamellar keratoplasty (DALK) due to keratoconus. Patients and methods. This observational case-control study included total 53 eyes of 53 patients with keratoconus and underwent DALK surgery. All patients were evaluated preoperatively and 3 months after suture removal with CT. In CT, anterior chamber depth (ACD), iridocorneal angle (ICA), anterior chamber volume (ACV), central corneal thickness (CCT), maximum keratometric value (Kmax), flattest simulated meridian keratometry (SimK1), steepest simulated meridian keratometry (SimK2) and simulated keratometry average (SimKavg) results were compared before and after DALK surgery. Results. A significant increase was observed in CCT values after DALK surgery (p &lt; 0.001). Patients showed statistically significant decrease in Kmax, SimK1, SimK2 and SimKavg values (p &lt; 0.001 for all). Postoperative ACD and ACV values were significantly lower (p &lt; 0.001). The ICA values showed no significant difference (p = 0.183) between preoperative and postoperative values (49,95 ± 5,85 and 46,30 ± 11,33 respectively). Conclusion. We determined a dramatic decrease in keratometric values, ACD and ACV values and an increase of corneal thickness after DALK surgery. Although DALK can be performed without interfering with the anterior chamber, has a significant effect in anterior chamber.

Outcomes of large-diameter deep anterior lamellar keratoplasty and converted two-piece mushroom penetrating keratoplasty for herpetic corneal scars.

To report the clinical outcomes of large diameter deep anterior lamellar keratoplasty (DALK) and converted two-piece microkeratome-assisted mushroom keratoplasty (MK) for herpetic corneal scars. In this single-centre study, large diameter (9 mm) DALK was attempted in consecutive patients with herpetic corneal scars. In case of macroperforation or unsatisfactory clearance of the optical zone, the procedure was intraoperatively converted to two-piece microkeratome-assisted MK. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, endothelial cell density (ECD), immunologic rejection, herpetic recurrence and graft failure rates in the two groups. DALK was successfully performed in 98 of 120 eyes, while the remaining 22 eyes required intraoperative conversion to MK. At 5 years, mean logMAR BSCVA was 0.10 ± 0.12 in the DALK group and 0.09 ± 0.15 in the MK group (P = 0.75). Refractive astigmatism at 5 years was 2.8 ± 1.4 D in the DALK group and 3.0 ± 1.7 D in the MK group (P = 0.67). ECD was higher in the DALK group than in the MK group at all time points (P < 0.001), with a mean annual cell loss of 10.9% after MK and 4.2% after DALK. The 5-year risk for immunologic rejection (DALK: 3%, MK: 5%, P = 0.38), herpetic recurrence (DALK: 6%, MK: 9%, P = 0.38), and graft failure (DALK: 4%, MK: 5%, P = 0.75) were comparable in both groups. Large diameter (9 mm) DALK yields excellent visual and clinical outcomes in eyes with herpetic corneal scars. In case of intraoperative complications, DALK can be converted to two-piece microkeratome-assisted MK to maximize the refractive benefit of a large diameter graft while minimizing the risk of endothelial failure.