Surgical Corneal Anatomy in Deep Anterior Lamellar Keratoplasty: Suggestion of New Acronyms

Sarnicola, Enrica; Sarnicola, Caterina; Cheung, Albert Y.; Holland, Edward J.; Sarnicola, Vincenzo

doi:10.1097/ico.0000000000001845

Cited by 25 publications

(50 citation statements)

References 70 publications

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“…DM perforation is the most frequent intraoperative complication during DALK. 3,9,13 It generally occurs during manual dissection or while completing the stromal removal following a big bubble (BB). A partial full-thickness trephination is rare because it is largely avoidable with a careful examination of the patient’s preoperative pachymetry; in our experience, we have had only one case over more than 1500 DALK procedures.…”

Section: Discussionmentioning

confidence: 99%

“…This technique provides important advantages compared to penetrating keratoplasty (PK), primarily the avoidance of endothelial rejection and longer graft survival. 1 –6 Descemet’s membrane (DM) rupture is the most common intraoperative complication with DALK and the principal cause of PK conversion, with the subsequent loss of all DALK advantages. 7 –9 The PK conversion rate progressively decreases as the surgeon’s ability to manage and repair DM ruptures increases.…”

Section: Introductionmentioning

confidence: 99%

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Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination

Sarnicola¹,

Sarnicola²,

Cheung

et al. 2020

European Journal of Ophthalmology

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Purpose: The aim of this study was to describe a surgical technique to perform deep anterior lamellar keratoplasty (DALK) despite inadvertent full thickness trephination in one quadrant. Methods: Case report of a 19-year-old boy who underwent DALK for visually significant post-infectious stromal scar in his left eye. An unintentional full thickness trephination occurred in the upper-nasal quadrant at the beginning of the surgery. After suturing the perforated area, manual DALK was performed, and an air bubble was left in the anterior chamber. Evaluated outcomes included best spectacle corrected visual acuity (BSCVA), residual recipient bed thickness, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double anterior chamber. Results: The surgery was completed without any further complications. No double anterior chamber or Urrets–Zavalia syndrome was observed on the first postoperative day. Mean residual recipient bed thickness was 72 μm and regular. ECC was 2446 cell/mm2. BSCVA at 18 months of follow-up was 0.9. There were no episodes of rejection, and the graft remained clear at the last follow-up (4 years). Conclusion: Inadvertent partial full thickness trephination of the recipient cornea is a largely preventable but possible complication during DALK. Penetrating keratoplasty conversion can be avoided by performing a manual dissection DALK.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination

Sarnicola¹,

Sarnicola²,

Cheung

et al. 2020

European Journal of Ophthalmology

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“…1,3,11,12 Although different strategies have been described to repair DM ruptures, this complication can be difficult to manage. 2,13 –16 This is especially true in manual DALK cases (previously referred to as pdDALK but now simply DALK according to the new classification 12,17,18 ) when the recipient bed is considerably flatter or steeper than the donor graft. 15,19 The purpose of this study is to report our experience in managing this clinical scenario when it leads to a refractory double anterior chamber (AC).…”

Section: Introductionmentioning

confidence: 99%

Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

Sarnicola¹,

Sarnicola²,

Cheung

et al. 2020

European Journal of Ophthalmology

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Purpose: To report how to manage a specific type of Descemet’s membrane (DM) rupture during manual DALK with a concurrent donor–recipient disparity of curvature. Methods: Case report of two patients that had DM rupture during manual DALK with a concurrent donor–recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a “DSEK autograft,” was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. Results: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). Conclusion: The existence of a donor–recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor–recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

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“…Various techniques for DALK have been developed over the past two decades including manual, hydro-dissection and pneumatic dissection, and vary in the amount of stroma removed. 8 The big bubble (BB) technique was initially described by Anwar and Teichmann in 2002, and is thought to leave behind the least amount of residual stroma, cleaving a plane between a “pre-Descemet layer” (PDL) (Type 1 BB), the DM itself (Type 2 BB) and the rest of the stroma, or a mixed plane partially exposing both PDL and DM (Type 3 BB). 8 , 9 , 10 , 11 , 12 …”

Section: Introductionmentioning

confidence: 99%

Granular corneal dystrophy recurrence at the posterior graft-host interface after type 1 big bubble deep anterior lamellar keratoplasty

Oke

Haddad

Lee

2020

American Journal of Ophthalmology Case Reports

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Purpose To describe our observations of granular corneal dystrophy (GCD) recurrence isolated to the posterior graft-host interface after type 1 big bubble (BB) deep anterior lamellar keratoplasty (DALK). Observations We performed a retrospective chart review of 3 eyes in 2 patients, and literature review to summarize GCD recurrence patterns after DALK. A 29-year-old man with GCD underwent DALK by type 1 BB technique. Three years following surgery, he was found to have recurrence of GCD deposits isolated to the posterior graft-host interface. Similarly, a 53-year-old woman with GCD underwent DALK by BB type 1 technique, and was noted to have trace residual deposits at the posterior graft-host interface that increased in number and size over the course of 6 years. Her fellow eye underwent DALK with type 2 BB formation, without evidence of graft-host interface recurrence over a four year period. Our literature review describes the recurrence patterns of 18 cases of GCD following DALK. Conclusions and importance DALK can be prone to GCD recurrence in the central posterior graft-host interface. Recurrent deposits isolated to the posterior graft-host interface following type 1 BB DALK supports the hypothesis that GCD recurrence may be due to residual pathologic keratocytes in the pre-Descemet layer (PDL).

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Surgical Corneal Anatomy in Deep Anterior Lamellar Keratoplasty: Suggestion of New Acronyms

Cited by 25 publications

References 70 publications

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination

Total or subtotal full thickness recipient bed cut to repair donor–recipient curvature disparity in cases of DM rupture with manual DALK

Granular corneal dystrophy recurrence at the posterior graft-host interface after type 1 big bubble deep anterior lamellar keratoplasty

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