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Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick Children Toronto, Ontario, Canada Disclosure: The author has no financial interests related to the material of this poster. Abstract Purpose To present a series of pediatric patients who underwent deep anterior lamellar keratoplasty (DALK) for stromal opacities or ectasia by one surgeon from 2007-2009. Methods A retrospective review of 12 consecutive patients with attempted DALK, age less than 18 years and follow-up of at least 4 months was performed. Indications for surgery, length of follow-up, complications and initial and final visual acuity were recorded. Results Successful DALK was performed in 12 eyes of 11 patients aged 1-17 years old. There was one macroperforation and conversion to penetrating keratoplasty. Non-healing epithelial defects occurred in 2 patients who developed microbial keratitis. Repeat DALKs were performed successfully. One patient developed reactivation of HSV in the graft and because of dense amblyopia a repeat graft was not attempted. Final visual acuity was unchanged or improved in all patients. Conclusions Deep anterior lamellar keratoplasty is a safe alternative to penetrating keratoplasty in children with corneal stromal opacities or ectasia. Methods Records of 13 eyes of 12 consecutive patients with attempted DALK were reviewed Single surgeon from 2007-09 Surgical technique used ◦ Melles technique (1 case) ◦ Manual dissection (12 cases) Trephination (Hessberg-Barron, 300-350 microns) Sharp and semi-sharp dissection to pre-Descemet’s plane Air injected to visualize stroma but big bubble not attempted Results 12/13 eyes underwent successful manual DALK 1 eye was converted to PKP because of macroperforation 4 microperforations occurred but dissection was completed successfully 2 repeat DALKs (with tarsorraphy) were performed after persistent epithelial defects resulted in bacterial keratitis – both remain clear Vision remains unchanged or improved in all patients Grafts are clear in 11/12 eyes with mean followup of 11.8 months (range 6-22) Table 1: Pre-operative characteristics Patie Age nt Eye Diagnosis Other Pre-op BCVA 1 9 mo RE Herpes simplex CS UM* 2 9 yr RE Phlectenulosis 20/400 3 14 yr RE Keratoconus 14 yr LE Keratoconus Fix + follow 4 15 yr RE Hurler syndrome 20/200 5 1 yr LE Corneal dermoid 6 8 yr LE ? Herpes zoster 7 2 yr LE Bacterial keratitis Neurotrophic cornea 8 16 yr LE Keratoconus Eye-rubber, OCD, Tourettes CF 9 8 yr RE Descemetocele Posterior blepharitis 20/40 10 14 yr LE Bacterial keratitis Soft contact lens wearer 20/70 11 5 yr RE Exposure keratopathy Goldenhar syndrome, lid coloboma repair 20/800 12 13 yr LE Keratoconus Autism, eye-rubber Linear nevus sebaceous Fix + follow CS UM* 20/100 LP CF * Central, steady + unmaintained Table 2: Operative details Patient Eye Residual opacity Donor/recipi Intraoperative complications / ent (mm) comments 1 RE - - Macroperforation, converted to PKP 2 RE No 7.75 /7.5 None 3 RE No 7.75 /7.5 None LE No 8.0 /7.5 None 4 RE Yes 8.0 /7.5 Microperforation 5 LE No 7.0 /6.5 Previous crescentic graft, subsequent cataract extraction /IOL /pupilloplasty 6 LE Yes 8.0 /7.5 Microperforation 7 LE No 7.25 /7.0 None 8 LE No 8.5 /8.0 None 9 RE Yes 7.75 /7.5 Microperforation 10 LE No 8.25 /8.0 Microperforation 11 RE No 7.75 /7.5 None 12 LE No 8.0 /7.5 None Table 3: Post-operative course Patie nt Eye Complications Post-op BCVA Follow Comments -up 1 RE Graft rejection 20/200 2 RE None 20/40 22 mo 3 RE None 20/40 12 mo LE None 20/50 6 mo 4 RE None 20/80 6 mo Sutures in 5 LE None 20/200 20 mo Dense amblyopia 6 LE Suture loosening at 6 weeks 20/60 11 mo Amblyopia 7 LE ? HSV reactivation + scar HM 13 mo Opted not to regraft 8 LE None 20/40 8 mo 9 RE Persistent epi defect, bacterial ulcer, regraft 20/40 22 mo 10 LE None 20/20 12 mo 11 RE Persistent epi defect, bacterial ulcer, regraft 20/200 14 mo 12 LE None 20/50 6 mo Ambylopia Tarsorraphy Amblyopia Figure 1: Slit lamp photo of patient 6 showing anterior stromal scar and thinning Figure 2: Slit lamp photo of patient 12 showing Vogt striae and deep scarring Discussion DALK was selected instead of PKP in our pediatric patients because of a lower risk of rejection and greater tectonic strength. Two of our patients (3 and 8) were forceful eye rubbers with psychiatric co-morbidities and the improved strength was reassuring. A manual technique instead of a big bubble technique was used to allow dissection of deep scars and minimize perforations, as we believe the benefit of reduced rejection outweighs the visual benefits in this patient group with other ocular co-morbidities especially amblyopia. The high rate of perforation may reflect the deep scarring in some corneas and also surgeon inexperience. Satisfactory visual outcomes were achieved even when residual corneal opacities remained in the recipient bed. Persistent epithelial defects lead to bacterial superinfection in two patients and we now perform temporary and permanent tarsorraphies following DALK surgery in susceptible patients. Conclusions Manual DALK in children leads to improved visual outcomes, and in our view has significant advantages over PKP in this high risk group.