Download 13381: Deep Anterior Lamellar Keratoplasty in Patients With Full

Dr Charmaine Chai
Dr Ray Manotosh
Dr Anna Marie Tan
Prof Donald Tan
National University Hospital
The authors have no financial interests to disclose
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To present our intra-operative, and postoperative outcomes of patients who
underwent manual Deep Anterior Lamellar
Keratoplasty (DALK) for full thickness corneal
pathologies.
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Retrospective case series
Case records of all patients who underwent a
keratoplasty from 2011 to 2014 in the
National University Hospital (NUH) were
reviewed and
Patients who underwent a DALK for various
full-thickness corneal pathologies were
identified
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Outcome measurements recorded include
intra-operative and post-operative
complications, and best-corrected visual
acuity (BCVA).
Surgical technique and details of intraoperative findings were recorded.
All donor corneas were obtained from the
Singapore Eye Bank and graded using the
Singapore Eye Bank grading system.
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Of the 140 keratoplasties performed in NUH,
38 were DALKs (27.1%).
7 patients underwent a DALK by a single
surgeon (Professor Donald Tan) between June
2012 and August 2014
◦ 5 patients had significant corneal scarring from
previous full thickness corneal laceration repairs
◦ 2 patients presented with corneal perforation, 1
secondary to active marginal keratitis, while the
other secondary to a sterile corneal ulcer from
blepharokeratitis and chronic use of topical steroids
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Intra-operatively, 5 out of 7 patients (71.4%) had
inadvertent DM perforation with entry into the
anterior chamber.
◦ None of the cases had a persistent double anterior chamber
that required surgical intervention.
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Of the 6 patients who were seen at least 6 months
after surgery, 4 patients (66.7%) achieved a BCVA of
6/12 (LogMAR 0.3) or better.
◦ 1 patient was still aphakic (LogMAR 3) at last follow-up
◦ 1 patient had a residual posterior stromal scar with high
astigmatism (LogMAR 0.88)
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There were no cases of graft rejection by last followup
The longest follow-up was at 30 months postoperatively, of which the graft remained clear
Figure 1 – Pre-operative anterior segment photograph of a patient who presented
with a corneal perforation secondary to Blepharokeratitis and chronic topical steroid
use.
Figure 2 – Post-operative anterior segment photographs at week 1 (A) and month 4 (B)
Figure 3 – Pre-operative photographs of the right (A) and left (B) eye of the patient
who presented with a perforated corneal ulcer secondary to recurrent marginal
keratitis
Figure 4 – Post-operative anterior segment photographs of the left eye at month 21
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Traditionally, the decision to perform a DALK
versus a PK is based on the corneal
endothelium health.
With improved instrumentation and surgical
techniques, DALK can be performed with
good visual outcomes.
By avoiding a full thickness keratoplasty, we
believe that we have significantly decreased
the risk of endothelial rejection and other
associated risks of a PK.
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High incidence of DM perforation is not
unexpected given the nature of the cases that
were selected.
Though a double anterior chamber may be seen
in the initial post-operative phase, all eventually
resolved with no need for surgical intervention
In the event of DM perforation, small amount of
residual stromal may be left behind.
Good visual outcome can still be achieved if the
pathological area is mostly excised and the
central visual axis is relatively clear and almost
down to the DM.
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DALK can be performed as an alternative
surgical procedure even in the presence of a
defective descemet membrane.
Good visual outcome and minimal postoperative complications can be achieved with
modifications and improvements in surgical
techniques.
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