Outcomes of Repeat Anterior Lamellar Keratoplasty

Abstract

Purpose: To describe the outcomes and complications of repeat anterior lamellar keratoplasty (ALK) after a failed primary ALK. Methods: This was a retrospective case series. Twenty-three eyes of 22 patients who underwent repeat ALK for optical indications from January 1, 1991, to December 31, 2017, were included. Clinical data were recorded from the Singapore Corneal Transplant Study database. Outcome measures were graft survival, best-corrected visual acuity (BCVA), and complications. Results: Of the 780 cases of ALK performed for optical indications during the study period, 23 cases (2.9%) underwent repeat ALK. Primary ALK comprised of 16 deep ALK and 7 automated lamellar therapeutic keratoplasty cases. After repeat ALK, 21 eyes had further dissection down to the descemetic or predescemetic plane, whereas 2 eyes had graft exchange for failed automated lamellar therapeutic keratoplasty. The graft survival of repeat ALK was 93.2%, 86.1%, and 78.3% at 1, 3, and 5 years, respectively. There were 4 cases of graft failure with a mean time to failure of 2.0 ± 1.7 years. After the repeat ALK procedure, 63.6% and 66.7% of eyes achieved a BCVA of LogMAR +0.3 (20/40) or better at 1 and 2 years, respectively. Five eyes (17.4%) had an intraoperative microperforation. Conclusions: In the case of a failed ALK graft for a range of optical indications, a repeat ALK procedure offers a viable and safe surgical option with good long-term graft survival and visual outcomes, while avoiding the various disadvantages of performing penetrating keratoplasty, especially the risk of allograft endothelial rejection.

Pneumatic Dissection for Large-Diameter (9-mm) Deep Anterior Lamellar Keratoplasty in Eyes With Previous Anterior Lamellar Keratoplasty

“…11 Moreover, unlike in virgin eyes, repeat keratoplasty after ALK is often complicated by postoperative changes in corneal anatomy from the presence of a partial-thickness corneal wound. The vertical plane of the previous ALK wound can be characterized by stromal scarring and fibrosis, 16,17 which can pose challenges during cannular insertion for big-bubble formation.…”

“…Specifically, deep trephination at 9 mm effectively bypasses the area of scarring from the previous surgery (usually at 8-8.5 mm) and allows insertion of the cannula beneath the previous graft and at the appropriate depth for successful bubble formation. 17 Because the removal of the previous lamellar graft before pneumatic dissection might undesirably cause the injected air to escape anteriorly resulting in insufficient build-up of intrastromal pressure for big-bubble formation, the use of a trephination diameter larger than the ones for ALK avoids the unintentional removal of the previous lamellar graft, thus maintaining the necessary dynamics for successful pneumatic dissection. 6,18 In this series, residual bed thickness varied significantly between eyes that had undergone SALK or epikeratophakia (central residual bed thickness $373 mm in all cases) and those that had undergone other types of ALK (central residual bed thickness $132 mm in all cases).…”

“…The incidence of perforation in this series was much lower than that reported in an interventional series of 23 repeat ALK procedures using various techniques. 17 Second, the peripheral stromal crown reduces the tendency to make superficial loose suture passes and provides protection during suturing, which has been observed as one of the main causes for perforation during DALK. 27 Third, the peripheral crown results in a lap-joint configuration similar to stepped PK wounds.…”

Keratoplasty Registries: Lessons Learned

“…21 2016-2021: DMEK results, 123 DMEK versus DSAEK, 65 and longterm outcomes of PK/DSAEK/DALK. 35,39,64,66,124 Data enrolled in the SCTS could be viewed as national or as singlecentered data with standardized care. 47 changing practice patterns of corneal transplants for keratoconus, 77 and nationwide reduction of grafting for keratoconus after cross-linking implementation.…”

Indications and Surgical Techniques for Repeat Corneal Transplantation in Eastern China: A Twelve-Year Study

“…However, with the development of various lamellar keratoplasties and endothelial keratoplasties in recent decades, its use has gradually expanded in repeat keratoplasty. [12][13][14] Renovations of surgical techniques provide more customized options in repeat keratoplasty and to a certain extent improve surgical outcomes [13,15]. To the best of our knowledge, although several investigations on repeat corneal transplantation have been published [4,9,16], the studies on clinical characteristics of repeat keratoplasty in China was rather limited, especially on multiple keratoplasties.…”