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      Factors Predicting Unsuccessful Big Bubble Deep Lamellar Anterior Keratoplasty

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          Abstract

          Purpose: To evaluate the role of corneal structural resistance as a surgical failure factor in deep lamellar keratoplasty (DLK). Method: A total of 10 eyes of 10 patients underwent DLK at the Ophthalmic Hospital in Rome. The big bubble technique was performed for deep stromal dissection by air injection. Seven patients were affected by advanced keratoconus and corneal thinning ranging from 441 to 235 µm. Two patients were affected by central corneal opacity from herpetic keratitis, and one patient suffered from corneal leucoma caused by bacterial keratitis. Clinical follow-up comprising final astigmatism and visual acuity findings were evaluated with a minimum follow-up of 12 weeks. Results: DLK was successfully performed in eight eyes, five of which were affected by moderate to advanced keratoconus and three by post-infective corneal opacity. In these patients preoperative ultrasonic pachymetry ranged between 441 and 287 µm. In the remaining two patients a perforation of the Descemet’s membrane (DM) occurred while attempting to separate it from the overlying stroma by the big bubble technique, requiring a penetrating keratoplasty (PK) to be performed. In both cases preoperative ultrasonic pachymetry was below 250 µm. Both perforations occurred at a different site than the needle site and at the operative time of the big-bubble injection. Discussion: An ultrastructurally weakened DM may suffer a loss of resistance to a stressing force, becoming unable to tolerate the big bubble technique, and thus being perforated. Since the weakening of the DM is related to end-stage keratoconus corneal thinning, the preoperative corneal thickness rather than the surgeon’s ability can play a major role in surgical failure of DLK. Our study reveals a very high risk of perforation of the DM when pre-operative total pachymetry is below limit of 250 µm.

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          Most cited references 9

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          Comparison of deep lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus.

          To compare the therapeutic outcomes after deep lamellar keratoplasty (DLK) and penetrating keratoplasty (PK) in patients with keratoconus. Retrospective case-control study. We reviewed the clinical notes of 47 patients diagnosed clinically with keratoconus who had received DLK (26 eyes of 25 patients) or PK (25 eyes of 22 patients) at Moorfields Eye Hospital or the Royal Shrewsbury Hospital between 1994 and 2001. The patients in the 2 groups were matched for severity of their keratoconus by preoperative visual acuity. Deep lamellar keratoplasty was performed with the Melles technique in 7 eyes and the technique described by Sugita and Kondo in 19 eyes. Penetrating keratoplasty was performed with a standard technique using a Hessburg-Barron trephine. A single continuous 16-bite 10-0 nylon suture was placed and adjusted in both groups. Best-corrected visual acuity (BCVA), refractive results, surgical techniques for DLK, and complication rates were analyzed. The 25 patients with keratoconus who underwent DLK had a mean age of 32.6 years and a median follow-up of 28 months. The mean age of the 22 patients who underwent PK for keratoconus was 34 years. This group was followed up for a median time of 55 months. The median final BCVA of patients in the DLK group was 6/9 and in the PK group 6/6 (no statistical significance). The median result for the final spherical equivalent power in both groups was mild myopia, although the DLK group had more myopia, and the median astigmatism was less than 5.00 diopters cylinder for both groups. Complication rates were similar for DLK and PK, although the nature of the complications varied. Penetrating keratoplasty is no longer an automatic choice for the surgical treatment for keratoconus; DLK seems to be a safe alternative. Best-corrected visual acuity, refractive results, and complication rates are similar after DLK and PK. Deep lamellar keratoplasty is more technically challenging but allows the risk of endothelial rejection to be avoided and may reduce the risk of late endothelial failure.
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            Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement.

             J Kondo,  J Sugita (1997)
            Deep lamellar keratoplasty (DLK) was performed to restore visual acuity in 120 eyes with corneal stromal opacification. DLK is believed to be an effective treatment in eyes in which endothelial cell function had been preserved, and in which there was no epithelial or stromal oedema. The purpose of this study was to evaluate the effectiveness of this treatment. The stroma was excised to the extent that only Descemet's membrane remained, at least in the optical zone. Donor corneas of full, or almost full, thickness with Descemet's membrane removed, or which had been lathed to a thickness of 0.4 mm from the endothelial side, were attached by suturing. In 113 eyes which were observed for 6 months or more postoperatively in which average prospective visual acuity was 0.09, average postoperative visual acuity improved to 0.6. Specular microscopy 1 month postoperatively revealed average endothelial cell counts of 2225 (SD 659)/mm2, while 24 months postoperatively this value was 1937 (642)/mm2 (cell loss 13%). Puncturing of Descemet's membrane during surgery occurred in 47 of 120 eyes (39.2%), but after 12 months, there was no difference in visual acuity or number of endothelial cells between these eyes and those in which no puncturing had occurred. There was no postoperative endothelial rejection reaction with DLK, and restoration of postoperative visual acuity was quite adequate. Compared with penetrating keratoplasty, DLK allows endothelial cell counts to be maintained for a longer period. In addition, results can be expected to be more consistent over the long term with DLK.
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              A new surgical technique for deep stromal, anterior lamellar keratoplasty

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                Author and article information

                Journal
                OPH
                Ophthalmologica
                10.1159/issn.0030-3755
                Ophthalmologica
                S. Karger AG
                0030-3755
                1423-0267
                2006
                November 2006
                10 November 2006
                : 220
                : 6
                : 379-382
                Affiliations
                aOphthalmic Hospital, Rome, and bDepartment of Ophthalmology and Neurosurgery, University of Siena, Siena, Italy
                Article
                95864 Ophthalmologica 2006;220:379–382
                10.1159/000095864
                17095883
                © 2006 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Tables: 1, References: 20, Pages: 4
                Categories
                Original Paper

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