Preferred practice pattern and observed outcome of deep anterior lamellar keratoplasty – A survey of Indian corneal surgeons

Abstract

Purpose: This study aimed to assess the preferred surgical technique and outcome of deep anterior lamellar keratoplasty (DALK) among corneal surgeons in India. Methods: An online questionnaire-based cross-sectional survey was conducted among members of the Cornea Society of India (CSI) with experience of performing >10 DALK procedure. The responses pertaining to their surgical experience, preferred technique, complications, and outcome of DALK were collected and analyzed. Results: A total of 156 responses were received. In total, 35.9% of participants reported annual keratoplasty of >50, and DALK constituted >25% surgeries for 25% of participants. Ectatic corneal disorder was reported as the most common indication for DALK by 71.6% of the respondents. Big-bubble (BB) DALK (W A -1.82) was the most preferred technique, along with suction trephine (50%) for partial trephination and bottom port cannula (45.5%) for BB formation. On statistical analysis, no difference was observed in the surgeon reported success rate of BB formation with or without anterior lamellar keratectomy (ALK) (χ2 (1,156) = 3.1498, P = 0.08) or paracentesis (χ2 (1,156) = 0.2737, P = 0.60) before stromal air injection, and method of stromal air injection (χ2 (1,156) = 4.7325, P = 0.09). Conversion to penetrating keratoplasty was reported by 16% of participants in >25% cases, while 66.7% reported in <10% cases. Cataract and double anterior chamber were the most common complications. 50% of participants suggested that >20 procedures are required to overcome the learning curve. Conclusion: BB DALK is the most commonly practiced DALK technique, and its success is independent of ALK and paracentesis being performed prior to air injection and method of air injection (cannula/needle).

Preferred practice patterns for keratoconus: An e-survey among Indian cornea specialists

“…[ 31 ] The authors opined that good results from single-center or small groups working in well-resourced academic centers may not be achieved by a larger group of corneal surgeons outside these centers. Despite these findings, DALK remains a preferred surgical technique for keratoconus in India[ 32 ] and other countries. [ 33 ]…”

“Groove and Peel” Deep Anterior Lamellar Keratoplasty: How Deep Can You Go?

“…Among various DALK techniques that have been described to date, 6–9 the “big-bubble” technique represents the most popular approach, 10–12 mainly because the removal of stroma to the level of Dua layer is believed to produce optimal visual outcomes; the air injection creates intracorneal cleavage at the pre-Descemetic level, aiding the removal of stroma. 13,14 However, its success and adoption rate are often undermined by its technical difficulty.…”

“…13,14 However, its success and adoption rate are often undermined by its technical difficulty. 10–12 Intrastromal air injection can quickly lead to corneal opacification and poor intraoperative visualization, precluding a second bubble attempt. A recent study reported that even experienced surgeons achieved the desired type 1 bubble in 61.7% of cases, whereas no bubble was achieved in 12.8% of cases.…”

Commentary: Deep anterior lamellar keratoplasty: The challenges and solutions

“…The survey reports that DALK constitutes >25% of the keratoplasty cases in only about one fourth of the participants. [ 2 ] In spite of its numerous advantages over penetrating keratoplasty (PK), including a much lower graft rejection rate, better reversal after rejection, and earlier suture removal, the uptake of DALK among keratoplasty surgeons has been relatively slow owing to its steep learning curve, technical complexity, and longer operative times compared with PK. Stromal dissection for barring the Descemet membrane (DM) remains the most challenging component of DALK.…”

“…Corneal ectasia, which has been the classical indication for DALK, continues to remain the most common indication for the procedure in our country. [ 2 ] The recent therapeutic advancements for treating the disease, such as corneal collagen cross-linking and contact lens technology have, however, led to a decline in the number of keratoconus cases requiring DALK for advanced progressive disease and visual rehabilitation, respectively. Continued advances in the field are expected to further reduce the number of patients who would require the DALK in the coming future.…”