Deep Lamellar Endothelial Keratoplasty Research Articles

Stability of vision, topography, and endothelial cell density from 1 year to 2 years after deep lamellar endothelial keratoplasty surgery

To evaluate whether the visual, topographic, and endothelial cell count results observed 1 year after deep lamellar endothelial keratoplasty (DLEK) surgery remain stable up to 2 years after surgery. Prospective, noncomparative, interventional case series. Twenty eyes of 20 patients with corneal edema from Fuchs' endothelial dystrophy. Deep lamellar endothelial keratoplasty endothelial replacement surgery, with a 9.0-mm or 9.5-mm scleral access incision and a specialized intrastromal trephine, was performed. Snellen visual acuities, corneal topography, and endothelial cell counts were prospectively measured preoperatively and 1 year and 2 years after DLEK. Uncorrected and best spectacle-corrected visual acuity (BSCVA), refractive and topographic astigmatism, mean corneal curvature, topographic regularity and symmetry, and endothelial cell density. At 1 year postoperatively, BSCVA averaged 20/50 (range, 20/25-20/200), spherical equivalents (SE) averaged -0.194+/-1.521 diopters (D), manifest refraction (MR) astigmatism averaged 2.04+/-1.05 D (range, 0.0-4.0 D), topographic astigmatism averaged 2.3+/-1.1 D, mean corneal curvature was 43.2+/-1.8 D, the surface regularity index (SRI) averaged 1.16+/-0.41, and the surface asymmetry index (SAI) averaged 1.05+/-1.09. At 2 years postoperatively, BSCVA averaged 20/48 (range, 20/25-20/200), SE averaged -0.369+/-1.267 D, MR astigmatism averaged 1.76+/-0.66 D (range, 0.75-3.0 D), topographic astigmatism averaged 2.4+/-1.1 D, mean corneal curvature was 43.6+/-1.8 D, the SRI averaged 1.13+/-0.44, and the SAI averaged 0.76+/-0.59. There was no significant change in visual or topographic parameters between 1 year and 2 years postoperatively (P>0.05). Endothelial cell counts averaged 2335+/-468 cells/mm(2) at 1 year and 2151+/-457 cells/mm(2) at 2 years postoperatively (P = 0.041). Deep lamellar endothelial keratoplasty provides stable refractions, corneal topography, and endothelial cell densities as long as 2 years after surgery. The absence of corneal sutures in this technique seems to prevent the sutures in/sutures out changes in SE refractions and corneal topography sometimes seen after penetrating keratoplasty (PK). Deep lamellar endothelial keratoplasty is, therefore, an excellent alternative to PK for patients with endothelial dystrophies.

Corneal endothelial transplantation: results of a clinical series using deep lamellar endothelial keratoplasty (DLEK).

We present the results of our clinical series replacing posterior stroma and endothelium only by deep lamellar endothelial keratoplasty (DLEK) in patients with corneal endothelial diseases. Through a 9.0-mm superior scleral incision, a deep stromal pocket was created across the cornea. A 7.5-mm posterior lamellar disc of recipient tissue was excised and replaced by same-size donor posterior disc without suture fixation. Three cases were followed for 12 months after DLEK. Best spectacle-corrected visual acuity (BSCVA), endothelial cell density, and corneal thickness were examined. At 12 months after surgery, all transplants were clear and in position. In the 3 cases, BSCVA at 12 months was 20/200 (hand motion before operation), 20/50 (6/200 before operation), and 20/60 (20/250 before operation), respectively. In one patient, postoperative endothelial cell density was 533 cells/mm(2) with a very thin donor disc. In the other two patients, postoperative endothelial cell density was >2000 cells/mm(2). Corneal thickness (+/-SD) averaged 0.51 +/- 0.06 mm. DLEK in the setting of corneal endothelial diseases is an effective surgical procedure without corneal surface incisions and sutures.

Ceratoplastia endotelial lamelar profunda em distrofia de Fuchs: relato de caso

To report a case of deep lamellar endothelial keratoplasty (DLEK) technique applied to a patient with Fuchs' dystrophy. The surgical procedure was performed on the right eye for a case of Fuchs' dystrophy with endothelial failure. Through a 9 mm self-sealing scleral tunnel incision, a stromal pocket was dissected at 0.35 mm depth. A 8.5 mm lamellar donor disc with 0.150 mm thickness, containing posterior stroma, Descemet's membrane and endothelium, was transplanted without corneal suture. Best spectacle-corrected visual acuity, biomicroscopy, topography, ultrasound pachymetry and endothelial cell density were evaluated. Before surgery, the patient presented best spectacle-corrected visual acuity of 20/100 (+4.00 -3.25 x 60o), astigmatism of 6.60 D (37.5 a 12o x 44.1 a 102o), ultrasound pachy-metry of 0.625 mm and endothelial cell density of 720 cel/mm2. Three months after surgery, best spectacle-corrected visual acuity was 20/30 (-1.25 -0.50 x 45o), astigmatism was 1.00 D (37.2 a 75o x 38.2 a 165o); ultrasound pachymetry showed 0.503 mm and endothelial cell density showed 2447 cel/mm2. Complications: intraoperative iris cut, disc edge dislocation, wrinkled disc and interface nebula. The preliminary results suggested that deep lamellar endothelial keratoplasty is an alternative to surgical treatment of Fuchs' dystrophy with endothelial failure. A greater number of cases and longer follow-up are necessary to better understand this keratoplasty technique and its outcome.

Rapid visual rehabilitation after endothelial transplants with deep lamellar endothelial keratoplasty (DLEK)

To evaluate the speed of visual recovery in 30 consecutive patients with Fuchs endothelial dystrophy who received deep lamellar endothelial keratoplasty (DLEK) transplant surgery.Best spectacle-corrected visual acuity (BSCVA) by manifest refraction and uncorrected visual acuity (UVA) were prospectively measured at preop, at 1 week, and at 1, 3, 6, 12, and 18 months after DLEK. The LogMAR of the postop vision was compared against each patient's preop vision. Visual results at 6 months were also compared against potential acuity meter (PAM) results in 27 patients. All eyes had reached at least the 6-month follow-up interval.Two of the first 32 eyes originally enrolled in the protocol were converted at surgery to standard penetrating keratoplasty (PK), and so DLEK data were obtained on 30 eyes for this report. Average BSCVA and UVA were better than preop vision at every time point, achieving statistical significance by 3 months (P < 0.05). Average preop BSCVA was 20/162 (range 20/40 to CF), improving to 20/63 at 3 months (range 20/25 to 20/200), 20/56 at 6 months, 20/51 at 1 year, and 20/46 at 18 months. Of the 27 patients who had PAM testing, 52% (14 of 27) had BSCVAs within 1 line of their PAM at 3 months, 63% (17 of 27) were within 1 line at 6 months, 71% (12 of 17) were within 1 line at 1 year, and 83% (10 of 12) were within 1 line at 18 months (P < 0.05 compared with preop from 3 months on).DLEK surgery preserves the normal corneal surface topography and allows rapid visual recovery of useful vision by 3 months. The visual acuity continues to improve over time.

Microkeratome-assisted deep lamellar endothelial keratoplasty

To observe the indication, surgical principle, clinical results and complications of microkeratome-assisted deep lamellar endothelial keratoplasty (DLEK). DLEK was performed in six patients with bullous keratopathy. One of the six patients underwent DLEK combined with vitrectomy under temporary artificial corneal and intraocular foreign-body removal. Another underwent DLEK combined with vitrectomy and posterior chamber intraocular lens implantation. The patients were followed up for 6 approximately 9 months. The postoperative best-corrected visual acuity showed clear improvement in 5 cases. Endothelial cell density averaged (2481 +/- 212) cells/mm(2). Pachymetry averaged (549 +/- 61) micro m. Astigmatism averaged (2.04 +/- 1.19) D. No serious complication was found. DLEK is an alternative choice for PKP. It may offer further advantages over conventional PKP surgery, and could serve as a surgical technique in endothelial keratoplasty. A long-term follow-up in a larger patient population is needed to confirm our initial results.

Rapid visual rehabilitation after endothelial transplants with deep lamellar endothelial keratoplasty (DLEK).

To evaluate the speed of visual recovery in 30 consecutive patients with Fuchs endothelial dystrophy who received deep lamellar endothelial keratoplasty (DLEK) transplant surgery. Best spectacle-corrected visual acuity (BSCVA) by manifest refraction and uncorrected visual acuity (UVA) were prospectively measured at preop, at 1 week, and at 1, 3, 6, 12, and 18 months after DLEK. The LogMAR of the postop vision was compared against each patient's preop vision. Visual results at 6 months were also compared against potential acuity meter (PAM) results in 27 patients. All eyes had reached at least the 6-month follow-up interval. Two of the first 32 eyes originally enrolled in the protocol were converted at surgery to standard penetrating keratoplasty (PK), and so DLEK data were obtained on 30 eyes for this report. Average BSCVA and UVA were better than preop vision at every time point, achieving statistical significance by 3 months (P < 0.05). Average preop BSCVA was 20/162 (range 20/40 to CF), improving to 20/63 at 3 months (range 20/25 to 20/200), 20/56 at 6 months, 20/51 at 1 year, and 20/46 at 18 months. Of the 27 patients who had PAM testing, 52% (14 of 27) had BSCVAs within 1 line of their PAM at 3 months, 63% (17 of 27) were within 1 line at 6 months, 71% (12 of 17) were within 1 line at 1 year, and 83% (10 of 12) were within 1 line at 18 months (P < 0.05 compared with preop from 3 months on). DLEK surgery preserves the normal corneal surface topography and allows rapid visual recovery of useful vision by 3 months. The visual acuity continues to improve over time.

Lamellar keratoplasty - new concepts

New concepts of lamellar keratoplasty techniques mainly deal with the refinement of the so-called deep lamellar endothelial keratoplasty (DLEK). The aim of the deep lamellar technique is to expose bare Descemet's membrane of the recipient and to suture in a full thickness graft. Graft rejections are not known with DLEK. We describe the preparation techniques of Anwar, Melles, and Krumeich and discuss the advantages and disadvantages. The femtosecond laser enables the surgeon to cut the cornea non-mechanically with a cutting accuracy of +/- 10 microns. Fuchs endothelial dystrophy can be treated by posterior lamellar keratoplasty (POLK). In this technique only a sheet of Descemet's and endothelium are replaced. In severe alkali burn with limbal stem cell deficiency a lamellar corneo-scleral disc can be grafted in order to restore the limbus. Routine central penetrating keratoplasty should follow at least half a year later.

Deep lamellar endothelial keratoplasty (DLEK): pursuing the ideal goals of endothelial replacement.

Endothelial dysfunction is a leading cause of corneal vision loss and treatment requires surgical replacement with donor endothelium. Standard penetrating keratoplasty (PK) suffers from the inherent problems of surface corneal incisions and sutures and poor wound healing of vertical stromal wounds. This often results in high irregular astigmatism, unpredictable corneal power, and the risk of long-term visual loss from suture-induced vascularization, ulceration, rejection, and late wound rupture. This paper delineates five ideal goals of endothelial replacement, which include: (1) a smooth surface topography without significant change in astigmatism from preoperative to postoperative; (2) a highly predictable and stable corneal power; (3) a healthy donor endothelium that resolves all oedema; (4) a tectonically stable globe, safe from injury and infection; and (5) an optically pure cornea. Deep lamellar endothelial keratoplasty (DLEK) is a surgical method of endothelial replacement that is performed through a limbal scleral incision that leaves the surface of the recipient cornea untouched. The early results of this innovative surgery are discussed and compared to the results of PK in terms of fulfillment of the five ideal goals of endothelial replacement. With further refinement of interface creation, DLEK surgery may be the ideal method for endothelial replacement.

Discussion by

Dr. Terry and Ms. Ousley describe the 6-month and 12-month data for the first U.S. clinical trial of a new surgical approach for the correction of corneal edema secondary to endothelial cell failure. Corneal edema from endothelial cell dysfunction, as in Fuchs’ dystrophy, aphakic bullous keratopathy, and pseudophakic bullous keratopathy, is the leading cause for penetrating keratoplasty in this country. Penetrating keratoplasty (PK) is still the gold standard for endothelial replacement in treating these diseases. Recently, new surgical techniques have been devised to replace only the posterior stroma and endothelium in a lamellar fashion. These procedures include: deep lamellar endothelial keratoplasty (DLEK), as described by Dr. Terry; endokeratoplasty, as described by Drs. Bussin and Arffa; endothelial lamellar keratoplasty, as described by Dr. Culbertson; and microkeratome-assisted posterior keratoplasty, as described by Dr. Azar.

Replacing the endothelium without corneal surface incisions or sutures: the first United States clinical series using the deep lamellar endothelial keratoplasty procedure

Purpose To report the 6- and 12-month results of the first United States clinical series of deep lamellar endothelial keratoplasty (DLEK) in the treatment of endothelial dysfunction. Design Prospective, noncomparative, interventional case series. Participants Eight eyes of eight patients with corneal edema from Fuchs’ dystrophy and pseudophakia. Methods A 9.0-mm limbal, scleral, partial-depth incision provided access for a deep lamellar corneal pocket dissection. A 7.5- to 8.0-mm posterior lamellar disc of recipient tissue was then excised and replaced through the pocket with a same size donor disc containing healthy endothelium. A temporary air bubble in the anterior chamber was used for donor tissue adherence, and no surface corneal incisions or sutures were necessary. Main outcome measures Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction astigmatism, TMS-1 topography, ultrasonic pachymetry, Orbscan topography, and endothelial cell density were evaluated. Intraoperative and postoperative complications are reported. Results At 6 and 12 months after surgery, all eight corneas were clear and the grafts were healed in good position. At 6 months, the BSCVA varied between 20/30 and 20/70, the average change in astigmatism from before surgery was +1.13 diopters (D; ±1.50 D), the average change in corneal power was −0.4 D (±1.7 D), the average pachymetry was 648 μm (±134 μm), and the average endothelial cell count was 2290 cells/mm 2 (±372 cells/mm 2). At 12 months, three of the four eyes reaching this time gate were 20/40 or better, with a change in astigmatism from before surgery of only +0.81 D (± 0.55 D), a corneal power change of −1.3 D (± 0.4 D), and an endothelial density of 2409 cells/mm 2 (± 154 cells/mm 2). One of the original nine eyes entered into this study required conversion to standard penetrating keratoplasty as a result of a microperforation during recipient pocket dissection and has experienced no ill effects. Conclusions The DLEK procedure, with its absence of corneal surface incisions and sutures, is a safe procedure that preserves the normal corneal topography, minimizes astigmatism and corneal power changes, and provides a healthy donor endothelial cell count and function. If interface optical clarity can be maintained, then this technique offers considerable advantages over penetrating keratoplasty in the treatment of endothelial dysfunction.

Use of indocyanine green in deep lamellar endothelial keratoplasty

A new technique using indocyanine green (ICG) during deep lamellar endothelial keratoplasty (DLEK) to stain the corneal stroma of the donor disk facilitated surgical placement of the disk in the host corneal opening created to match the donor disk. Two female patients, aged 82 and 77 years, had ICG staining of the donor corneal disk during DLEK for pseudophakic bullous keratopathy and Fuchs’ corneal dystrophy. By 24 hours postoperatively, no ICG was detected clinically by biomicroscopy of the sutureless (no corneal sutures) lamellar transplanted corneas. This is the first report of the use of ICG during DLEK and the first intrastromal use of ICG in the human cornea. The use of ICG facilitated the DLEK procedure and appears to be safe for intraoperative use in the cornea..

A new approach for endothelial transplantation: deep lamellar endothelial keratoplasty.

A new approach for endothelial transplantation: deep lamellar endothelial keratoplasty.