Deep Anterior Lamellar Keratoplasty - Techniques

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1 Deep Anterior Lamellar Keratoplasty - Techniques SHERAZ DAYA MD FACP FACS FRCS(Ed) FRCOphth

2 Financial Disclosure Company Code 1. Abbott Medical Optics Inc. S 2. Bausch + Lomb C,L 3. Carl Zeiss Meditec C 4. Clarvista C 5. Ellex L 6. Excellens C, O 7. LinCor Biosciences C 8. Medicem C 9. Nidek, Inc. C,L 10. Physiol L 11. PRN O 12. STAAR Surgical C 13. Strathspey Crown C 14. Scope Pharmaceuticals C 15. Rayner C C = Consultant / Advisor E = Employee L = Lecture Fees O = Equity Owner P = Patents / Royalty S = Grant Support

3 Primo No Nocere DALK Why? SAFETY SURVIVAL long term OTHER

4 INDICATIONS: Lamellar Keratoplasty WHENEVER THE ENDOTHELIUM IS NORMAL

5 Anterior Lamellar Keratoplasty Advantages Retains endothelium Reduces risk of long term corneal blindness Decreases hazards of PK Disadvantages (previously cited) Poor Vision Interface opacification Regular and Irregular Astigmatism Technical skill

6 PK can be HAZARDOUS!!!

7 PK Hazards Expulsive Choroidal Haemorrhage 0.56*-1% Rejection & Failure Reduced survival of Regrafts Glaucoma 19-30% Cataract Endophthalmitis

8 PK long term

9 Do Lamellars Reject? Epithelial Rejection Sub-epithelial Rejection

10 DALK vs PK for Keratoconus

11 Visual (optical) Keratoconus Corneal Stromal dystrophies & degenerations Deep corneal scarring Traumatic post infective HSV, HZV other stromal scars

12 Tectonic higher risk for PK Corneal ectasia ( focal such as pellucid marginal degeneration, diffuse, or post full thickness grafting) Corneal melt (autoimmune, neurotrophic, or infectious) Traumatic corneal perforation Peripheral corneal thinning Mooren s ulcer Terrien s marginal degeneration collagen disease and other autoimmune diseases

13 DALK - Post Perforation

14 Ocular surface disease Stevens Johnson Syndrome (SJS) Chemical or thermal injury Ectodermal dysplasia Corneal stromal scarring or thinning from ocular surface disease

15 Ocular Surface Disease Special situation Prior experience all PKs in time failed* LKs survived GOAL: Tectonic or improve clarity * Ilari L, Daya SM: Long-term outcomes of keratolimbal allograft for the treatment of severe ocular surface disorders. Ophthalmology Jul;109(7):

16 Corneal Melt in prev DALK

17 GRAFT SURVIVAL by Diagnostic Category Keratoconus (98%) Corneal Scarring 7 7 (100%) HSV / HZV (95.2%) Ocular Surface Disease 15 8 (53.2%) Tectonic (perforation) 8 5 (62.5%) n Clear Graft survival 110% 100% 90% 80% 70% 60% 50% 40% year 1 year 2 year 3 year 4 year 5 keratoconus herpetic therapeutic/tectonic

18 DALK How? Descemet s Big Bubble Anwar Viscodissection Pre-Descemet s Optical Recognition Melles Femtosecond Assisted

19 Ferrara Cheesewire

20 Big Bubble Mohamed Anwar* Anwar M, Teichmann KD Big-bubble technique to bare Descemet's membrane in anterior lamellar keratoplasty J Cataract Refract Surg Mar;28(3): Big-bubble technique to bare Descemet's membrane in anterior lamellar keratoplasty.

21 Stromal injection of Air Air accumulates and cleaves PDL Courtesy Luigi Fontana, MD Removal of anterior stroma Perforate remaining stroma Courtesy Luigi Fontana, MD Courtesy Luigi Fontana, MD Courtesy Luigi Fontana, MD

22 Injection of Viscoelastic Removal of residual stroma Courtesy Luigi Fontana, MD Courtesy Luigi Fontana, MD Exposure of Descemet s /PDL Courtesy Luigi Fontana, MD

23 FSDALK Recipient

24

25

26 Big Bubble Type 1 Separates PDL thicker layer Central Bubble extends to 8.0mm Accompanying emphysema Type 2 At DM very thin Peripheral bubble extends to outside 8.0mm zone Little or no stromal emphysema

27 When is Big Bubble Contraindicated? Endothelial failure Scarring to DM / Pre-Descemet s Layer (PDL) Previous Hydrops? Large diameter DALK Avoidance of conversion to PK Down s Syndrome Paediatric Keratoplasty Keratoglobus

28

29

30 Manual DALK Dissection GOALS DEEP as possible Descemet s level best SMOOTH as possible CORNEAL ANATOMY Posterior lamellae = less densely packed

31 DEEP ANTERIOR LAMELLAR KERATOPLASTY MELLES Pre-Descemet s dissection* Technique of Melles -Limbal incision - Air in AC - Posterior dissection of whole cornea - Viscoelastic to separate posterior lamellae - Trephination * Br J Ophthalmol 1999;83:

32 Modified Melles Determination of Graft Size

33 Partial thickness trephination

34 PARACENTESIS OUTSIDE area of Dissection

35 AQUEOUS REPLACED WITH AIR

36 Air - Endothelium Interface black band Air - endothelium interface acts as a convex mirror Black band = 2 X residual stromal depth

37 Achieve appropriate depth wrinkles in Descemet s

38 Deep dissection with a blunt spatula* *Daya Lasik Spatula, (John Weiss Ltd. UK)

39 Removal with Curved Corneal Scissors

40 Descemet s membrane exposed

41 Donor Descemet s Membrane Stripped Trypan Blue (Vision Blue)

42 Suturing the Graft

43 Graft Sutured

44

45 Post DALK on Hydrops

46

47 Eyes (%) DALK on Hydrops Best spectacle corrected visual acuity (BSCVA) /12 or better 6/24-6/ Worse than 6/ m 3m 6m 12m Last visit Follow up (months)

48

49 Conclusions DALK Endothelial preservation technique Safer option than PK Long term corneal survival Better outcomes Newer techniques Experience Always a good first option PK can always be performed later Excellent skill to acquire

50 Deep Anterior Lamellar Keratoplasty WORTH CONSIDERING WHENEVER THE ENDOTHELIUM IS NORMAL!!!

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