Descemet Membrane Perforation Research Articles

Clinical outcome after air-assisted manual deep anterior lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment.

PurposeFungal keratitis remains an important disorder because of difficulty in its diagnosis, and some patients do not respond to medical treatment using antifungal local and systemic agents. This study was carried out to determine the therapeutic value of air-assisted manual therapeutic deep anterior lamellar keratoplasty (TDALK) in the treatment of fungal keratitis not curable by antifungal chemotherapy.MethodsSeventeen patients (18 eyes) who were referred to Fukuoka University Hospital and treated surgically from January 2006 to April 2018, in whom a diagnosis of fungal keratitis was confirmed by typical clinical findings and microbiological or histological analysis of corneal specimens, and who were poorly responsive to topical and systemic antifungal medication, whereas the lesion had not resulted in corneal perforation, were enrolled in this study and were treated by air-assisted manual TDALK. Clinical outcomes including treatment course, therapeutic success rate, visual acuity outcomes and graft clarity rate were analyzed.ResultsThe most common pathogen was Fusarium, followed by Candida and Aspergillus. Beneficial therapeutic results (a clear or translucent graft) were achieved in 15 of 18 eyes (83%). There was no recurrence of infection and resulting visual acuity ≤0.15 logarithm of minimal angle of resolution unit was achieved in 15 eyes (83%). Intraoperative microperforation of Descemet’s membrane (DM) was not observed in any patients.ConclusionAir-assisted manual TDALK can be effective for treating severe fungal keratitis. In addition, air-assisted manual TDALK might be an alternative procedure to big-bubble DALK, because it can provide ambulatory vision and can preserve potentiality of vision with less risk of intraoperative perforation of DM.

Effect of Keratoconus Severity on Clinical Outcomes After Deep Anterior Lamellar Keratoplasty

To evaluate the effect of keratoconus severity on the visual and refractive outcomes and complications after deep anterior lamellar keratoplasty (DALK). Consecutive interventional case series. This study enrolled 227 keratoconus-affected eyes that underwent DALK. Amsler-Krumeich keratoconus classification was used to categorize the patients: stage II, 47 eyes; stage III, 60 eyes; and stage IV, 120 eyes. The outcome measures, including postoperative best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction, mean keratometry, keratometric astigmatism, and complications, were analyzed and compared based on keratoconus stage. The mean patient age was 27.6 ± 8.0 years, and the mean follow-up period was 38.0 ± 19.8months. No significant differences were observed in postoperative BSCVA (P= .55), spherical equivalent refraction (P= .27), mean keratometry (P= .09), and keratometric astigmatism (P= .14) among the groups. Improvement in BSCVA were significantly greater in stage III and stage IV compared with stage II (P= .04 and P < .001, respectively). The decrease in spherical equivalent was significantly greater in stages III and IV compared with stage II (P= .04 and P= .001, respectively). Mean keratometry decreased to a greater degree in stage IV compared with stages II and III (P < .001 for both comparisons). The study groups were comparable with respect to intraoperative Descemet membrane perforation, the rate of successful big-bubble formation, suture-related complications, and graft rejection. DALK is a safe and effective procedure for the treatment of all stages of keratoconus. This technique of corneal transplantation is more effective in eyes with severe keratoconus compared with those with moderate keratoconus.

Deep Anterior Lamellar Keratoplasty for Keratoconus: Multisurgeon Results

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.

Incidence and Outcomes of Intraoperative Descemet Membrane Perforations During Deep Anterior Lamellar Keratoplasty

To report the incidence and outcomes of intraoperative Descemet membrane (DM) perforations during deep anterior lamellar keratoplasty (DALK). Retrospective, consecutive, interventional case series. A retrospective audit of all DALK cases performed from 2004 to 2015 in a tertiary center, with and without intraoperative DM perforations. We excluded cases with preexisting corneal perforations before surgery. There were a total of 540 eyes, of which 101 (18.7%) had intraoperative DM perforations. These included 79 eyes (78.2%) with microperforations and 15 eyes (14.9%) with macroperforation. The most common steps at which DM perforation occurred intraoperatively were during deep lamellar dissection (32 cases; 31.7%), air injection (27 cases; 26.7%), and suturing (21 cases; 20.8%). Management of the DM perforations included a combination of intracameral air tamponade (49 cases; 48.5%), stromal patching (10 cases; 9.9%), fibrin glue (8 cases; 7.9%), and suturing of the defect (1 case; 1.1%). There were 2 eyes (2/540; 0.37%) that were converted to penetrating keratoplasty (PK). There were no significant differences in the postoperative unaided or best-corrected visual acuity, or in the numbers of patients with postoperative graft failure, graft rejection, or subsequent surgery at postoperative years 1 and 3. DALK cases with DM perforations intraoperatively are often able to be managed without conversion to PK. Cases with DM perforations intraoperatively have equivalent visual acuity outcomes compared to those without DM perforations, and did not have any increased risk of graft failure, rejection, or subsequent surgery at postoperative years 1 and 3.

Prediction of Descemet Membrane Perforation During Deep Anterior Lamellar Keratoplasty in Patients With Keratoconus With Stromal Scar.

To report big-bubble deep anterior lamellar keratoplasty (DALK) in patients with keratoconus with corneal stromal scar, and to investigate factors that can influence intraoperative Descemet membrane (DM) perforation. A retrospective study included patients with keratoconus with central stromal scar that underwent DALK using the big-bubble technique. Best spectacle-corrected visual acuity (BSCVA), keratometry, minimum corneal thickness (MCT), stromal scar depth, and endothelial cell density (ECD) were recorded. Receiver operating characteristic (ROC) curves were analyzed to predict an intraoperative perforation related to stromal scar. Thirty-eight eyes of 38 patients with keratoconus (mean age: 30.0±9.2 years) were included in this study. Thirty-four eyes had successful DALK; in four eyes, the procedure was converted to penetrating keratoplasty because of DM macroperforations. Successful big-bubble formation was achieved in 24 of 38 (63.2%) eyes, whereas in 10 eyes, manual dissection was used to complete the DALK. Mean preoperative and postoperative second year BSCVA were 1.3 (±0.4) and 0.5 (±0.2) logarithm of the minimum angle of resolution (P<0.001), keratometry values were 65.5±7.4 and 42.8±7.8 diopters (P<0.001), and ECD were 2,740±359 and 2,279±452 cells/mm (P<0.001), respectively. Using ROC analysis, the area under curve value to predict DM perforation was found to be 0.792 (scar/MCT ratio, P=0.04) and the best cutoff point for scar depth/MCT ratio was 53%. Big-bubble DALK is effective in patients with keratoconus with stromal scars. Scar depth/MCT ratio seems to predict the DM perforation.

Outcome of deep anterior lamellar keratoplasty patients with intraoperative Descemet's membrane perforation: A retrospective cross-sectional study.

Purpose:To evaluate functional and anatomical outcome in patients undergoing deep anterior lamellar keratoplasty (DALK) with intraoperative Descemet's membrane (DM) perforation (macro and micro).Methods:A retrospective cross sectional study (January 2009 to December 2015) of sixteen eyes of sixteen patients which included nine patients of advanced keratoconus (KC), two patients with paracentral DM scarring post hydrops, KC with Bowman's membrane scarring, macular corneal dystrophy and one patient of advanced Pellucid Marginal Degeneration (PMD). All underwent DALK with intraoperative DM perforation. Big bubble technique was attempted in all except in the two patients with post hydrops DM scar. Preoperative and postoperative best corrected visual acuity (BCVA), astigmatism and endothelial count (EC) were compared.Results:Postoperative BCVA and astigmatism were found to be better and statistically significant (’p value’ 0.00 and 0.003 respectively). BCVA preoperative and postoperative was 1.07± 0.3 and 0.28 ± 0.09 in LogMAR respectively and astigmatism pre and postoperative 4.14 ± 1.5 D and 2.7 ± 0.97 D respectively. Percentage decrease in EC at sixth postoperative week was 7.48% and at sixth month and 1 year postoperative was 15.1%. Two patients developed postoperative double anterior chamber and two patients developed pupillary block glaucoma and all were successfully managed.Conclusion:Not all patients of intraoperative DM perforation (including macro perforation) needs to be converted to penetrating keratoplasty. DALK can be successfully done if the perforation is identified early and managed adequately. This is the only known study which has shown a large series of successful DALK even with macro perforations.

Comparison of Outcomes in Patients Who Underwent Deep Anterior Lamellar Keratoplasty and Those Converted to Penetrating Keratoplasty.

Objectives:To compare clinical outcomes of cases who underwent deep anterior lamellar keratoplasty (DALK) and cases who were converted to penetrating keratoplasty (PKP) from DALK surgery.Materials and Methods:The records of 54 patients for whom DALK surgery was planned and were operated for different diagnoses between March 2013 and June 2015 were retrospectively analyzed. Patients were divided into two groups: group 1 (PKP group) consisted of 23 cases who were converted to PKP due to Descemet’s membrane perforation at any stage of surgery; group 2 (DALK group) consisted of 31 patients whose surgery could be completed as DALK. Preoperative and postoperative follow-up results were evaluated in each group.Results:Corrected distance visual acuity (CDVA) increased in the postoperative period according to baseline in both groups. However, there was no statistically significant difference in the rates of CDVA increase between the groups (p=0.142). The mean astigmatism measured by corneal topography at final examination was 5.8±2.3 diopters in group 1 and 5.4±1.8 diopters in group 2. The difference between groups was not statistically significant (p=0.430). The groups were not statistically different regarding postoperative pachymetry (p=0.453). The grafts in all 54 patients (100%) were clear at final postoperative examination. There were no statistically significant differences between the groups in terms of postoperative complications.Conclusion:Similar clinical outcomes were obtained in our study for patients who underwent DALK and those whose procedure was converted from DALK to PKP.

Triple procedure: cataract extraction, intraocular lens implantation, and corneal graft.

Corneal triple procedures consist of combined keratoplasty surgery and cataract surgery. Currently, anterior lamellar keratoplasty, endothelial keratoplasty, and conventional penetrating keratoplasty, are very often simultaneously performed with cataract surgery. The present article reviews the recent advances and current developments in corneal triple procedures. Many new findings have been reported. Core vitrectomy before host trephination and retroillumination during continuous curvilinear capsulorhexis has enabled us to perform penetrating keratoplasty triple procedures more safely. Type-1 big-bubble, baring Dua's layer, facilitates well tolerated anterior lamellar triple keratoplasty without Descemet membrane perforation. Descemet membrane endothelial keratoplasty triple procedure can provide excellent expected postoperative refraction. New techniques, including manual medium incision cataract surgery or glued intrascleral fixation of the intraocular lens with pupilloplasty, can be used for endothelial keratoplasty triple procedure, and frequent topical steroid administration can contribute to the reduction of postoperative cystoid macular edema. Recent technical advancements could contribute to safer and more effective corneal triple procedures. Triple surgery combined with novel procedures, including regenerative medicine and bioengineered corneal transplantation, will be performed in the near future.

Long-Term Outcomes of Deep Anterior Lamellar Keratoplasty Treating Posterior Stroma-Implicated Herpetic Corneal Opacities.

To evaluate the long-term outcomes of deep anterior lamellar keratoplasty for the management of deep stromal corneal opacities after herpes simplex keratitis (HSK) infection. Case records of patients who underwent deep anterior lamellar keratoplasty between January 2006 and June 2012 to treat HSK-related deep stromal corneal scars were retrospectively analyzed. The cases were divided into folds-on, folds-off, and no-folds groups based on the presence of stromal folds intraoperatively. The main outcome measures were best-corrected visual acuity, endothelial cell density, and complications. A total of 89 patients (89 eyes; 54 men and 35 women; 47.1 ± 12.9 years old) were included. Based on intraoperative events, 48 eyes had no stromal folds, 27 eyes had folds that were centrally peeled off, and 14 eyes had folds that could not be peeled. The average follow-up period was 50.4 ± 12.7 months. The mean best-corrected visual acuity improved from 1.63 ± 60.52 logMAR preoperatively to 0.44 ± 0.31 logMAR at the last visit (P < 0.001). Mean postoperative endothelial cell density was 1738 ± 573 cells per square millimeter. Eight eyes experienced HSK recurrence, 3 eyes had an episode of stromal rejection, and 3 eyes developed corneal endothelial decompensation. Cases in the folds-off group had a significantly higher rate of Descemet membrane microperforations compared with the other groups. Deep anterior lamellar keratoplasty is a viable alternative for the management of HSK-related deep stromal opacity. Although posterior corneal folds can be relieved intraoperatively in some of these cases, folds near Descemet membrane should be left in situ because of the high risk of Descemet membrane perforation.

Deep layers of the cornea and basic research in Spain

To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear.Prospective, nonrandomized cohort study at a tertiary referral center.Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking.The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket.Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens–corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded.Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D (P < 0.001) at 1 month after surgery and remained stable thereafter (P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery (P < 0.001), whereas BCLVA remained stable (P = 0.105). Mean thinnest-point pachymetry increased from 332±59 μm before surgery to 360±50 μm at the latest follow-up (P = 0.012), and no change in endothelial cell density was found (P = 0.355).With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.

Bowman Layer Transplantation to Reduce and Stabilize Progressive, Advanced Keratoconus

To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear. Prospective, nonrandomized cohort study at a tertiary referral center. Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking. The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket. Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded. Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D (P < 0.001) at 1 month after surgery and remained stable thereafter (P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery (P < 0.001), whereas BCLVA remained stable (P = 0.105). Mean thinnest-point pachymetry increased from 332±59 μm before surgery to 360±50 μm at the latest follow-up (P = 0.012), and no change in endothelial cell density was found (P = 0.355). With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.

Femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus and keratectasia.

To describe the initial outcomes and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK) for keratoconus and post-LASIK keratectasia. In this non-comparative case series, 10 eyes of 9 patients underwent DALK procedures with a femtosecond laser (Carl Zeiss Meditec AG, Jena, Germany). Of the 9 patients, 7 had keratoconus and 2 had post-LASIK keratectasia. A 500 kHz VisuMax femtosecond laser was used to perform corneal cuts on both donor and recipient corneas. The outcome measures were the uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), corneal thickness, astigmatism, endothelial density count (EDC), and corneal power. All eyes were successfully treated. Early postoperative evaluation showed a clear graft in all cases. Intraoperative complications included one case of a small Descemet's membrane perforation. Postoperatively, there was one case of stromal rejection, one of loosened sutures, and one of wound dehiscence. A normal corneal pattern topography and transparency were restored, UCVA and BCVA improved significantly, and astigmatism improved slightly. There was no statistically significant decrease in EDC. Our early results indicate that femtosecond laser-assisted deep anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology. This approach shows promise as a safe and effective surgical choice in the treatment of keratoconus and post-LASIK keratectasia.

Modified big-bubble deep anterior lamellar keratoplasty using peripheral air injection

PurposeTo introduce a modification to big-bubble deep anterior lamellar keratoplasty (DALK) which can decrease the risk of Descemet membrane (DM) perforation during air injection.MethodIn Anwar's big-bubble technique, a 27-guage needle...

Modified Miyake-Apple camera: illustration of deep anterior lamellar keratoplasty pearls learned from simultaneous anterior and posterior corneal imaging.

The aim of this study was to demonstrate surgical pearls in big-bubble deep anterior lamellar keratoplasty using a modified Miyake-Apple camera system and to correlate these findings with histology. This was a wet laboratory-based pilot study. Cadaveric human corneal tissue consented for research and not suitable for transplantation was fixed to a glass slide and assembled into the modified Miyake-Apple camera system. Dissections were performed and recorded. Selected specimens were submitted for light microscopy. Key points illustrated by video analysis included the entry of air into the artificial anterior chamber through the trabecular meshwork without Descemet membrane perforation, the contrast of this event with frank perforation, the potential of viscoelastic injection as a salvage maneuver, and the modes of air passage during the procedure. Histological correlation confirmed the air passage through the trabecular meshwork and demonstrated the appearance of pneumatized corneal stroma in the setting of a failed big-bubble and corneal "white-out." We present the video analysis that correlated with the histology of air behavior during big-bubble deep anterior lamellar keratoplasty. The chief points illustrated include signs associated with air entry into the eye in the presence and absence of Descemet perforation.

Nursing of femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus

Objective To explore the nursing of patients with keratoconus after performing the deep anterior lamellar keratoplasty assisted by femtosecond laser .Methods 9 patients with keratoconus hadfemtosecond laser-assisted deep anterior lamellar keratoplasty . Adequate preoperative , intraoperative and postoperative nursing care was performed .Results All the patients were satisfied with the results of sugery and their visual acuity were improved for various status .The purpose of treatment was achieved .One patient had intraoperative complication of small descemet membrane perforation .Conclusions Our early results of femtosecond laser-assisted deep anterior lamellar keratoplasty turn to be safe and effective .The key nursing care of preoperative period is to help patients make ophthalmic examination related to parameter settings of femtosecond laser , and the intraoperative period is to help patients coordinate with surgery and closely observe the changes of patients .The instructions of discharge and follow-up are also the important parts of consolidation the therapy outcomes . Key words: Nursing; Keratoconus; Femotosecond laser; Deep anterior lamellar keratoplasty

High-Resolution Optical Coherence Tomography–Guided Donor Tissue Preparation for Descemet Membrane Endothelial Keratoplasty Using the Reverse Big Bubble Technique

The aim of this study was to assess the feasibility of high-resolution spectral domain optical coherence tomography (HR-SDOCT) to guide donor tissue preparation in Descemet membrane endothelial keratoplasty using the reverse big bubble technique. Three corneoscleral discs were included in this ex vivo experimental study. A 27-G cannula was introduced into each cornea at the periphery by 3 different surgeons. Each surgeon attempted to achieve the ideal depth (pre-Descemetic plane) of the tip of the cannula for air injection to produce the reverse big bubble to separate the Descemet membrane (DM) from the posterior stroma. A supine optical coherence tomography system built at the Ophthalmic Biophysics Center of the Bascom Palmer Eye Institute was used to estimate in real-time the depth reached by the tip of the cannula in the posterior stroma during tissue preparation. After air injection, 1 successful big bubble was obtained, while each of the other corneoscleral discs had intrastromal emphysema and DM perforation. On HR-SDOCT evaluations, artifacts were noticed at the tip of the cannula. The successful big bubble demonstrated the separation of the DM and the stroma without intrastromal hyperreflectivity. Emphysema was visualized on the HR-SDOCT as a hyperdense intrastromal area shadowing the posterior structures of the anterior chamber. The HR-SDOCT-guided reverse big bubble technique may be a useful method to prepare donor tissue in Descemet membrane endothelial keratoplasty. Further improvements in high-resolution optical coherence tomography technology are needed this promising technique.

Novel spatula and dissector for safer deep anterior lamellar keratoplasty

Objective: We describe a novel spatula and dissector to facilitate the big-bubble technique in deep anterior lamellar keratoplasty (DALK). Methods: A 29-year-old man who was diagnosed with bilateral keratoconus underwent deep anterior lamellar keratoplasty (DALK). After 350μm partial thickness incision of the recipient cornea, the Bonfadini dissector was inserted at the deepest point in the peripheral incision and could be advanced to the center of the cornea safely because of its semi-sharp tip. After achieving the big-bubble (BB) separation of Descemet membrane (DM) from the overlying stroma, the anterior stromal disc was removed. Viscoelastic material was placed on the stromal bed to prevent uncontrolled collapse and perforation of DM during the paracentesis blade incision into the BB. We could detect the safe opening of the BB using the Bonfadini dissector by the leakage of air bubbles into the viscoelastic material. After injecting viscoelastic material into the BB space, we inserted the Bonfadini spatula into the bigbubble safely because of its curved profile and blunt edges. The groove along the length of the Bonfadini spatula enables safe and efficient incision or the residual stromal tissue using the pointed end of a sharp blade while protecting the underlying DM. After removal of posterior stroma, the donor button was sutured with 16 interrupted 10-0 nylon sutures. Results: This technique and the use of the Bonfadini spatula and dissector facilitate exposure of Descemet membrane. Conclusion: The smooth Bonfadini DALK spatula and dissector facilitate safe and efficient completion of DALK surgery.

Traumatic Wound Dehiscence After Deep Anterior Lamellar Keratoplasty

To analyze the outcomes of traumatic wound dehiscence after deep anterior lamellar keratoplasty (DALK). Retrospective and interventional case series. Single hospital. A total of 338 consecutive cases were reviewed. Eleven eyes that had wound dehiscence related to ocular trauma were included. Incidence and causes, best-corrected visual acuity (BCVA), and endothelial cell density were evaluated. Complications and secondary surgeries were recorded. Seven patients were male (63.6%) and 4 patients were female (36.4%), with a mean age of 30.6 years (range, 24-40 years). The incidence of wound dehiscence was 3.2% (11/338). The mean interval between the initial DALK procedure and wound dehiscence was 9.45 months (range, 2-16 months). The mean follow-up time was 6 years. The most common trauma was a fist blow injury (36.3%). Descemet membrane perforation was observed in 8 eyes (72.7%); lens damage and vitreous prolapse occurred in 2 eyes (18.1%). The final BCVA was 0.51 and was maintained in 4 eyes (36.3%). At the final visit, 10 grafts (90.9%) were clear. The mean endothelial cell loss was 55.8% between before DALK and last visit. Although the intact Descemet membrane protects against dehiscing traumas after DALK, a relative weakness at the graft-host junction tends to persist and a severe deforming force may result in graft dehiscence. This case series indicates that despite the fact that the visual results following the repair are acceptable, corneal endothelium seems to be subjected to severe damage, which puts graft survival chances at risk in the long term.

Long-Term Outcomes of Femtosecond Laser–Assisted Mushroom Configuration Deep Anterior Lamellar Keratoplasty

To review the long-term outcomes after femtosecond laser (FSL)-assisted mushroom configuration deep anterior lamellar keratoplasty (DALK). Noncomparative case series of 19 eyes from 19 patients who underwent FSL-assisted mushroom configuration DALK. Data were available for 14 eyes at 1 month, for 14 at 3 months, for 16 at 6 months, for 10 at 9 months, and for 8 at 1 year. Preoperative mean best-corrected visual acuity was 20/108 (range: 20/30-20/400). At 3 months, the mean best-corrected visual acuity was 20/46 (range: 20/25-20/250), and at a mean final follow-up of 13 months (range: 6-29) it was 20/35 (range: 20/15-20/200). The greatest change in mean spherical equivalent was at 3 months [-2.29 diopters (D), range: -7.38 to +3.38 D; from -9.54 D, range: -20.00 to +3.38 D, preoperatively]. There was 56% reduction in mean keratometric cylinder at 6 months (4.00 D, range: 1.04-8.75 D; from 9.13 D, range: 0.50-18.75 D, preoperatively). Complications included 3 cases (15.8%) of small Descemet membrane perforation, none of which required conversion to penetrating keratoplasty; 3 cases (15.8%) of stromal rejection that resolved with topical steroids; and 6 cases (31.6%) of steroid-related intraocular pressure rise that were treated with topical medications. Selective suture removal was initiated a mean of 3.5 months (range: 1.5-6 months) after surgery. The use of the FSL to perform corneal cuts in a mushroom configuration for DALK is reliable and reproducible. Earlier visual rehabilitation may be possible because of the mechanical stability and wound healing advantages of stepped corneal wounds.

Enzyme-Assisted Deep Anterior Lamellar Keratoplasty—A New Method of Lamellar Dissection—A Wetlab-Based Pilot Study

To explore the safety of a new technique of lamellar dissection, using enzymatic digestion of the corneal stroma and extracellular matrix. This was a wetlab-based pilot study of hyaluronidase and trypsin-assisted deep anterior lamellar keratoplasty (DALK) in cadaveric human corneal tissue. Enzyme-assisted DALK was performed on 17 tissues. These underwent histologic analysis using a pneumatic dissection specimen as control. Rates of perforation and Descemet membrane (DM) exposure were recorded by clinical observation and by optical coherence tomography in selected cases. Where possible, pre- and postsurgical endothelial cell counts were obtained via specular microscopy. Two tissues from the same donor were halved, with each half soaked in a different solution (Optisol, balanced salt solution, hyaluronidase, and trypsin) for 13.5 hours to observe maximal effect. Successful exposure of DM was achieved in 8 specimens. In the remaining 9, manual dissection was possible to a residual depth of 25 to 90 μm where measured with optical coherence tomography. Three tissues had perforation of DM, all via manual maneuvers. No deleterious effects on residual host tissue were observed by light microscopy with no significant rates of endothelial cell loss in 8 tissues in which a predissection cell count was obtainable. The 2 enzymes had differing effects on soaked specimens that were reflected intraoperatively. Preliminary results of this ex vivo study are encouraging that enzymolysis may represent an effective innovation in DALK surgery with an acceptable safety profile. Further studies are required to refine the technique and application of the enzymes in vivo.