Surgeon Preference for Keratoplasty Techniques and Barriers to Performing Deep Anterior Lamellar Keratoplasty

Abstract

To identify barriers and facilitators to adopting deep anterior lamellar keratoplasty (DALK) for nonendothelial corneal pathology.Methods: An anonymous survey consisting of 22 multiple choice and free text questions was designed to gather information on demographic factors of surgeons and DALK surgical practices. The survey was emailed to members of the kera-net, a global online corneal surgeon/surgery platform.Results: A total of 100 surgeons completed the survey, most of whom practice in the United States (73%). Most surgeons (89%) reported performing DALK. Surgeons who did not learn DALK during fellowship (34%) tended to be in practice for higher numbers of years (P , 0.001). Surgeons in private practice are more likely to perform DALK versus those in other settings (92.7% vs. 80.8%, P = 0.087). Surgeons performing more corneal surgeries (at least 100 per year) are more likely to perform DALK than those who perform fewer than 100 per year (52% vs. 14%, P = 0.01). Surgeons who perform Descemet membrane endothelial keratoplasty are more likely to perform DALK than those who do not (81.7% vs. 18.3%, P = 0.014). There was also a positive correlation between PK and DALK surgical volumes (Spearman rank correlation coefficient = 0.57, P , 0.001). The main reasons for surgeon preference for DALK over PK were a desire to preserve the endothelium, intraoperative safety, and decreased complications. Longer surgical time and low patient volume were cited as barriers to adoption of DALK.Conclusions: Alterations in DALK technique that reduce surgical time and providing more learning opportunities for DALK might improve adoption.

Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus: A Claims-Based Analysis

“…In one of our recent studies on barriers to DALK, even among DALK surgeons, there is variability in patient selection. 20 Thus, surgeon preferences may be useful to consider along with patient and clinical factors when exploring the regional differences in DALK and PK utilization.…”

Outcomes of Conventional 8.0-mm Versus Large 9.0-mm Diameter Deep Anterior Lamellar Keratoplasty for Keratoconus

“…14 In contrast to endothelial keratoplasty (EK), which has quickly gained acceptance and rapidly overtaken PK for the management of endothelial dysfunction, DALK has yet to achieve widespread adoption. 3 Although up to 86% of surgeons reportedly perform DALK, PK still makes up 38% of the total keratoplasty procedures performed in the United States in 2021, whereas DALK represents only less than 2% of cases. 4 Moreover, corneal stromal disease, which is the ideal primary indication for DALK, is managed in only 1 of 10 cases by means of this procedure.…”

“…[5][6][7] Consequently, most surgeons do not feel sufficiently compelled to face the learning curve in performing this procedure. 3 Instead, an improvement in visual and refractive outcomes, which are directly perceived by patients soon after suture removal, could provide the same surgeons with a greater incentive to transition to DALK.…”

Deep anterior lamellar keratoplasty for keratoconus: Elements for success

“…Despite these undisputed advantages, the uptake of DALK among corneal surgeons has been relatively slow, particularly in the U.S.[ 5 ] Longer surgical time, steep learning curve, and low patient volume and have been reported as the most important barriers to adoption of DALK. [ 6 ] Nevertheless, recent innovations in surgical technique, instrumentation and tissue preparation allowed standardization of DALK, with improved success rates even for inexperienced surgeons. [ 7 ]…”