How Much Progress Has Been Made in Corneal Transplantation?

Abstract

To assess the benefits of component lamellar corneal surgery, we investigated the surgical outcomes of deep anterior lamellar keratoplasty (DALK) for keratoconus and Descemet stripping automated endothelial keratoplasty (DSAEK) for laser iridotomy-induced bullous keratopathy (LI-BK). The results were compared with the surgical outcomes of penetrating keratoplasty (PKP). Seventy-nine eyes with keratoconus treated with DALK and 81 eyes with LI-BK treated with DSAEK were studied, and the graft clarity rate, best spectacle-corrected visual acuity, endothelial cell density (ECD), and surgical complications were compared with 273 eyes with keratoconus and 98 eyes with LI-BK all treated with PKP. Keratoconus eyes showed excellent visual outcomes with DALK and PKP, but graft survival was higher for PKP (100%, 98.9%, and 96.3% vs. 98.6%, 90.6%, and 86.1%, at 1, 3, and 5 years after surgery, respectively; P < 0.0001). There were no significant differences in the ECD up to 1 year after surgery. Greater ECD decline was observed for PKP at 3 and 5 years after surgery. Descemet membrane microperforation was observed in 49 eyes treated with DALK. Postoperative complications in eyes treated with PKP were increased incidence of immunological rejection and secondary glaucoma compared with eyes treated with DALK. LI-BK graft survival rates were excellent in both groups (DSAEK: 89.6% and 86.1%; PKP: 100% and 98.6%, 1- and 2-year rates, respectively; P = 0.17). Best spectacle-corrected visual acuity was better in the DSAEK group, and ECD showed a higher rate of decrease with DSAEK than with PKP. DALK and DSAEK considerably improved surgical outcomes in eyes with keratoconus and those with LI-BK, respectively. However, several key areas require further work, including development of safe surgical methods in DALK and prevention of early postoperative ECD loss in DSAEK.

Graft survival rate of deep anterior lamellar keratoplasty for keratoconus

“…A total of 2224 patients’ 11 graft survival rates from 9 studies [ 20 , 21 , 23 , 25 , 26 , 28 – 31 ] were analyzed. Three years after treatment with DALK, the merged graft survival rate was (95% CI): 92.9% (89.8–95.9%), P < .001 (Fig.…”

“…Ten survival rates of 1970 patients from 8 studies [ 21 , 22 , 24 – 26 , 29 – 31 ] were analyzed in this 5-year graft survival rate analysis. The merged graft survival rate was (95% CI): 90.4% (86.0–94.8%), P < .001 with a significant heterogeneity (I 2 value: 93.5%) (Fig.…”

Anatomical, clinical and surgical aspects of the posterior cornea

“…3). In both techniques, it is important to separate the Descemet membrane from the posterior stroma, both in the donor and in the recipient, and then adding the healthy part that the recipient is missing, achieving advantages that penetrating keratoplasty cannot overcome [9][10][11] .…”

Aspectos anatómicos, clínicos y quirúrgicos de la córnea posterior

“…3). En ambas técnicas es importante separar la membrana de Descemet del estroma posterior, tanto en el donador como en el receptor, para posteriormente agregarle la parte sana que haga falta al receptor, y lograr así ventajas que el injerto penetrante no puede superar [9][10][11] .…”