Big Bubble Deep Anterior Lamellar Keratoplasty for Management of Deep Fungal Keratitis

Abstract

Objective. To evaluate the therapeutic effect of big bubble deep anterior lamellar keratoplasty (DALK) in patients with deep fungal keratitis. Methods.Consecutive patients who had DALK for deep fungal keratitis at Shandong Eye Hospital between July 2011 and December 2012 were included. In all patients, the infiltration depth was more than 4/5ths of the corneal thickness. DALK surgery was performed with bare Descemet membrane (DM) using the big bubble technique. Corrected distance visual acuity (CDVA), graft status, and intraoperative and postoperative complications were monitored. Results. Big bubble DALK was performed in 23 patients (23 eyes). Intraoperative perforation of the DM occurred in two eyes (8.7%) during stromal dissection. The patients received lamellar keratoplasty with an air bubble injected into the anterior chamber. Double anterior chamber formed in 3 eyes (13.0%). Mean CDVA of the patients without cataract, amblyopia, and fungal recurrence was improved from preoperative HM/20 cm−1.0 (LogMAR) to 0.23 ± 0.13 (LogMAR) at the last followup (P < 0.01). Fungal recurrence was found in two patients (8.7%). Corneal stromal graft rejection was noted in one patient (4.3%). Conclusions. DALK using the big bubble technique seems to be effective and safe in the treatment of deep fungal keratitis unresponsive to medication.

Clinical evaluation of deep anterior lamellar keratoplasty using glycerol-cryopreserved corneal tissues for refractory herpetic stromal keratitis

“…[6,11,21,22] Moreover, in a long-term comparative study, the recurrence episodes were more severe and complicated in the PK group when compared with the DALK group. [23] Therefore, PK is commonly recommended in severe and progressive infections which are nonresponsive to medications, risking corneal perforation or scleral extension.…”

Epidemiology of fungal keratitis treated with penetrating keratoplasty by means of histopathologic findings

“…A deep penetration of the fungus in the cornea / eye, in turn, seems to go against the use of new transplant techniques such as lamellar keratoplasty for the treatment of fungal keratitis. Although lamellar keratoplasty will be described as an effective method for the treatment of fungal keratitis unresponsive to drug treatment (30)(31)(32) even in deep cases (31) , cases with deep infection seem more likely to recur after lamellar keratoplasty (33) . Shi et al show that partial lamellar keratoplasty is effective for fungal keratitis in which the infected injury lies in the middle or upper layers, especially when the corneal ulcer is quite widespread and non central (32) .…”

Surgical management of corneal infections

“…(42–45) Although technically more challenging, ALK theoretically decreases the risk of graft rejection and endothelial cell loss, and decreases the risk of introducing infectious material into the anterior chamber since the Descemet membrane is not breached. However, there is a risk of recurrence of the infection at the interface due to incomplete removal of the infectious organisms.…”

“…However, there is a risk of recurrence of the infection at the interface due to incomplete removal of the infectious organisms. (42) Gao and colleagues published their series of ALK in 23 patients with deep fungal ulcers that did not respond to medical therapy for at least two weeks. (42) They had good success rates with recurrence of fungal infection in 2 cases and graft rejection in only one case.…”

“…(42) Gao and colleagues published their series of ALK in 23 patients with deep fungal ulcers that did not respond to medical therapy for at least two weeks. (42) They had good success rates with recurrence of fungal infection in 2 cases and graft rejection in only one case. Sarnicola et al performed ALK in 11 eyes for Acanthamoeba and had no recurrences and no rejections.…”