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      Deep Anterior Lamellar Keratoplasty: Indications, Surgical Techniques and Complications

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          The concept of lamellar keratoplasty (LK) is not new. However, it had been abandoned and largely replaced by the time-honored technique of penetrating keratoplasty (PK) because LK is technically demanding, time consuming and gives suboptimal visual outcomes due to interface irregularity arising from manual lamellar dissection. Recent improvements in surgical instruments and introduction of new techniques of maximum depth of corneal dissection as well as inherent advantages such as preservation of globe integrity and elimination of endothelial graft rejection have resulted in a re-introduction of LK as an acceptable alternative to conventional PK. This review article describes the indications, different techniques, clinical outcomes and complications of deep anterior LK.

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          Most cited references 74

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          Big-bubble technique to bare Descemet's membrane in anterior lamellar keratoplasty.

          We describe a lamellar keratoplasty technique to bare Descemet's membrane in which air is injected to detach the central Descemet's. After a partial-thickness corneal trephination is performed, a disposable needle is inserted, deeply and bevel down, into the paracentral corneal stroma and air is injected. In most cases, this forms a large air bubble between Descemet's membrane and the corneal stroma. After anterior lamellar keratectomy is performed, a small opening is made in the air bubble and the remaining stromal layers are lifted with an iris spatula, severed with a blade, and excised with scissors. This technique is faster, safer, and easier to perform than previous methods.
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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.

                Author and article information

                Middle East Afr J Ophthalmol
                Middle East African Journal of Ophthalmology
                Medknow Publications (India )
                Jan-Mar 2010
                : 17
                : 1
                : 28-37
                Department of Ophthalmology, Labbafinejad Medical Center, Director of Cornea and Refractive Surgery Service, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
                Author notes
                Corresponding Author: Dr. Farid Karimian, Director of Cornea and Refractive Surgery Service, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: karimianf@ 123456yahoo.com
                © Middle East African Journal of Ophthalmology

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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