Deep Anterior Lamellar Keratoplasty: Surgical Technique, Indications, Clinical Results and Complications

Abstract

Deep anterior lamellar keratoplasty (DALK) is currently the procedure of choice to restore transparency and curvature in corneal stromal diseases with a healthy endothelium. Preserving the endothelium avoids endothelial rejection and provides a good and stable endothelial cell count, allowing good long-term graft survival. Several surgical techniques have been proposed over the last years, the most common of which include layer-by-layer manual dissection, hydrodissection, viscodissection, big bubble (needle or cannula) and air-viscobubble. Descemet's membrane rupture represents the most common complication, even in expert hands. The penetrating keratoplasty conversion rate gradually decreases as surgeons become more experienced and learn to manage Descemet's membrane ruptures. Being able to repair the ruptures would increase the success of DALK and allow patients to benefit from all of its advantages. a b cGüell JL (ed): Cornea.

Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

“…This disparity can be remedied with surgical relaxation of the recipient bed, specifically with a subtotal full-thickness circular cut of the recipient bed that preserves a hinge of the host bed at 6 o'clock. 11,12,15,16,19 Furthermore, cases where the recipient bed has greater curvature than the donor present an excess of tissue in the recipient bed that may create folds. If a DM break occurs in a fold, it may remain open creating a fixed and irreversible double chamber.…”

“…Postoperatively, the patient's head is positioned to promote air tamponade of the DM rupture. 15,19 Pharmacologic pupil dilation and careful monitoring of the patient are necessary to prevent pupillary block and a fixed dilated pupil (Urrets-Zavalia syndrome). These maneuvers were ineffective in fixing the DM ruptures in two cases, due to a disparity of curvature between the donor graft and the recipient bed.…”

“…This required a surgical correction of the donor-recipient curvature disparity. 15,19 This retrospective study adhered to the tenets of the Declaration of Helsinki. All surgeries were performed by a single surgeon (VS), under peribulbar anesthesia.…”

“…A 34-year-old man was referred to our practice for corneal leukoma of unknown etiology. 15,19 On presentation, the right eye demonstrated a complete dense infiltrate, with deep and superficial neovascularization (NV), normal intraocular pressure (IOP), and best spectacle corrected visual acuity (BSCVA) of hand motion (HM; Figure 1(a)). The left eye exam was normal with a 0.10 BSCVA.…”

“…2,13 –16 This is especially true in manual DALK cases (previously referred to as pdDALK but now simply DALK according to the new classification 12,17,18 ) when the recipient bed is considerably flatter or steeper than the donor graft. 15,19 The purpose of this study is to report our experience in managing this clinical scenario when it leads to a refractory double anterior chamber (AC).…”