Office-based Relaxing Incision Procedure for Correction of Astigmatism after Deep Anterior Lamellar Keratoplasty.

PURPOSE: To report the outcomes of a simple and effective office-based procedure for the correction of astigmatism after deep anterior lamellar keratoplasty (DALK). METHODS: This study enrolled 24 consecutive keratoconic eyes that developed an intolerable amount of graft astigmatism after DALK. The location and extension of steep semi-meridians were determined using corneal topography. Office-based relaxing incision procedures were performed at the slit-lamp biomicroscope using a 27-gauge needle. Relaxing incisions were made at the donor-recipient interface on one side of the steepest meridian with an arc length of 45° to 60° and an initial depth of approximately 70-80% of the corneal thickness. Topography was performed after 30-40 minutes and the initial incision was enhanced in depth and length. If an acceptable amount of astigmatism was not achieved, another incision was created at the opposite semi-meridian during the same session. RESULTS: Mean follow-up period was 13.1 ± 7.4 months. Mean preoperative best spectacle corrected visual acuity was 0.26 ± 0.14 logMAR, increasing to 0.22 ± 0.09 logMAR after the procedure (P = 0.20). Mean spherical equivalent refractive error increased from - 4.64 ± 3.06 diopters (D) preoperatively to -6.06 ± 3.15 D postoperatively (P = 0.01). Mean keratometric astigmatism was reduced by 2.95 ± 3.43 D and 5.16 ± 2.97 D measured using subtraction and vector analysis methods, respectively (P < 0.001). Microperforation occurred in one eye, which spontaneously improved with no sequelae. CONCLUSION: Office-based relaxing incision is a safe and effective procedure for the treatment of corneal graft astigmatism after DALK. This approach effectively decreases the need for the more costly alternative in the operating room.

Descemet Stripping Automated Endothelial Keratoplasty in Fuchs' Endothelial Dystrophy versus Pseudophakic Bullous Keratopathy.

PURPOSE: To compare clinical and confocal scan outcomes after Descemet stripping automated endothelial keratoplasty (DSAEK) performed for Fuchs' endothelial dystrophy (FED) versus pseudophakic bullous keratopathy (PBK). METHODS: This retrospective comparative study included 47 consecutive eyes of 39 patients with the diagnosis of FED (n = 29, group 1) or PBK (n = 18, group 2) that underwent DSAEK. Clinical outcomes were compared between the study groups. At the final follow-up examination, confocal microscopy was used to measure and compare central corneal and graft thickness as well as endothelial cell density and morphology between the two groups. RESULTS: Mean age at the time of surgery was 65.2 ± 11.8 and 69.4 ± 12.5 years in groups 1 and 2, respectively (P = 0.27). Follow-up period was 23.6 ± 14.0 months in group 1 and 25.6 ± 15.7 months in group 2 (P = 0.79). Postoperative best spectacle-corrected visual acuity was significantly better in group 1 than in group 2 until postoperative month 6. Afterwards, the two study groups were comparable in this regard. At the final follow-up examination, spherical equivalent refractive error was + 0.39 ± 1.46 diopters (D) in group 1 and + 0.80 ± 1.47 D in group 2 (P = 0.45). Postoperative keratometric astigmatism was 1.02 ± 0.83 D and 2.36 ± 0.67 D, respectively (P < 0.001). Mean central graft thickness was 98.0 ± 33.3 µm in group 1 and 107.6 ± 28.0 µm in group 2 (P = 0.45). No statistically significant difference was observed between the two groups in terms of the postoperative endothelial cell density. CONCLUSION: The outcomes of DSAEK surgery were comparable between FED and PBK. All grafts were clear despite the lower than normal endothelial cell counts.

Acute hydrops after deep anterior lamellar keratoplasty in a patient with keratoconus.

PURPOSE: To report the occurrence of acute hydrops 52 months after successful deep anterior lamellar keratoplasty (DALK) using the Anwar big-bubble technique in a keratoconic eye. METHODS: A 20-year-old man with a history of bilateral keratoconus who had undergone DALK in his right eye, presented with complaints of sudden visual reduction, photophobia, redness, and pain in the same eye. RESULTS: Review of his clinical course, slit-lamp biomicroscopy, and laboratory evaluation, including ultrasound biomicroscopy, revealed acute hydrops in the graft. He was medicated with hypertonic solutions but because of persistent graft edema and nonattached Descemet membrane, penetrating keratoplasty was performed. Histopathologic examination confirmed the diagnosis. CONCLUSIONS: Similar to penetrating keratoplasty, acute hydrops can occur after DALK using the big-bubble technique in patients with keratoconus.

Deep anterior lamellar keratoplasty versus penetrating keratoplasty for keratoconus: a clinical trial.

PURPOSE: To compare deep anterior lamellar keratoplasty (DALK) using the big-bubble technique to penetrating keratoplasty (PK) in patients with keratoconus. MATERIALS AND METHODS: In this clinical trial, patients with moderate to advanced keratoconus with poor spectacle-corrected visual acuity and intolerant to contact lens wear were enrolled. DALK was performed using the big-bubble technique, and a full-thickness donor cornea without Descemet membrane was sutured to the recipient bed. PK was performed conventionally with a Hessburg-Barron suction trephine. Three types of suturing were used for both groups. Postoperative refractive errors, best-corrected visual acuity (BCVA), contrast sensitivity function (CSF), and higher order aberrations (HOAs) were compared between the study groups. RESULTS: The study included 81 eyes of 81 patients. Forty-six eyes underwent DALK from which 4 were excluded because of failure to achieve bared Descemet membrane. Thirty-five eyes received PK. Mean patient age was 26.91 ± 7.9 versus 30.89 ± 10.3 years in the DALK and PK groups, respectively (P = 0.06). Mean follow-up period was 22.0 ± 7.9 months in the DALK group and 24.6 ± 3.5 months in the PK group (P = 0.32). Mean postoperative spherical equivalent refractive error was -3.23 ± 3.4 diopters in the DALK group versus -2.22 ± 4.6 diopters in the PK group (P = 0.28), and mean postoperative BCVA was 0.18 ± 0.08 and 0.15 ± 0.10 logarithm of the minimum angle of resolution, respectively (P = 0.12). CSF and total aberrations and HOAs were comparable in the study groups. CONCLUSIONS: DALK is an effective alternative surgical procedure for patients with keratoconus; the outcomes are comparable to PK in terms of refractive errors, BCVA, CSF, and HOAs.

Deep anterior lamellar keratoplasty in patients with keratoconus: big-bubble technique.

PURPOSE: To evaluate the visual and refractive outcomes after deep anterior lamellar keratoplasty (DALK) using the big-bubble technique in eyes with keratoconus. METHODS: In this case series, eyes with moderate to advanced keratoconus underwent DALK. All of them had unacceptable spectacle-corrected visual acuity or were contact lens intolerant. DALK was performed using the big-bubble technique. Full thickness donor cornea without Descemet's membrane (DM) was sutured to the recipient bed with three different suturing techniques. The visual acuity (presented in logMAR), refractive status, intraoperative and postoperative complications were evaluated. RESULTS: A total of 129 consecutive eyes of 121 patients were included. In 3 eyes, the operation was converted to penetrating keratoplasty. Therefore, 126 eyes (79 male) were enrolled in the study. Mean patient age at the time of surgery was 26.08 +/- 7.6 years. Mean follow-up period was 21.62 +/- 9.0 months. Mean preoperative corrected visual acuity was 1.27 +/- 0.4 logMAR, increasing to 0.25 +/- 0.2 logMAR at final follow-up examination (P < 0.001). Postoperative mean spherical equivalent refractive error, refractive and keratometric astigmatism were -3.41 +/- 3.1 D, 3.04 +/- 2.3 D, and 3.67 +/- 2.1 D, respectively. Bared DM was achieved in 103 eyes, whereas in 23 eyes pre-Descemet dissection was performed. DM perforation occurred in 5 eyes. The main complications encountered were filamentary keratitis, subepithelial graft rejection, and astigmatism. CONCLUSIONS: : DALK using the big-bubble technique appears to be a safe and effective procedure for eyes with moderate to advanced keratoconus. In case of extensive intraoperative DM perforation, it does not pose any limitation to ongoing penetrating keratoplasty.

Relaxing incisions combined with adjustment sutures for post-deep anterior lamellar keratoplasty astigmatism in keratoconus.

PURPOSE: To find an effective and reliable method to correct astigmatism after deep anterior lamellar keratoplasty (DALK) in patients with keratoconus. PATIENTS AND METHODS: This interventional case series included 14 eyes of 14 patients with keratoconus (12 males) undergoing graft refractive surgery (GRS) for intolerable post-DALK astigmatism. The technique of GRS for the 5 initial cases consisted of only relaxing incisions at the steep meridian in the graft-host interface down to Descemet membrane. For the rest, the relaxing incisions at the steep meridian were accompanied by simultaneous suturing and the effect of the relaxing incisions was controlled through selective suture removal starting a few days after the operation. The main outcomes were uncorrected and corrected visual acuity and change in refractive and keratometric astigmatism using subtraction and vector analysis methods. RESULTS: Mean patient age was 29.36 +/- 6.2 years. Mean time interval from complete suture removal to GRS and follow-up period were 4.5 +/- 2.0 months and 12.0 +/- 7.4 months, respectively. Mean preoperative best-corrected visual acuity was 0.29 +/- 0.1, increasing to 0.22 +/- 0.1 logarithm of minimum angle of resolution after the operation (P = 0.007). Average keratometric astigmatism was reduced by 3.8 and 5.5 diopters measured with subtraction and vector analysis methods, respectively. Four of 5 eyes that had only relaxing incisions initially required suturing of the incisions because of overcorrection, whereas preliminary results showed none of the 9 patients undergoing simultaneous relaxing incisions and suturing required further intervention. CONCLUSION: Relaxing incisions and suturing at the steep meridian followed by selective suture removal can effectively and predictably reduce post-DALK astigmatism in patients with keratoconus.

Deep anterior lamellar keratoplasty using the big-bubble technique in keratoconus.

PURPOSE: To evaluate the visual outcomes and complications of deep anterior lamellar keratoplasty (DALK) using the big-bubble technique in patients with keratoconus. METHODS: In this case series, 104 eyes of 99 patients with moderate to advanced keratoconus underwent DALK. All subjects were contact lens intolerant or had unacceptable spectacle-corrected visual acuity. DALK was performed using the big-bubble technique. Full thickness donor corneas devoid of Descemet's membrane (DM) were sutured to the recipient bed. Best spectacle-corrected visual acuity (BSCVA), refractive status, and intra- and postoperative complications were evaluated. RESULTS: Patients were male in 62.5%. Mean age of patients was 26.2±7.79 (range 15-46) years at the time of DALK and were followed for 23.07±8.1 (range 9-42) months. Mean BSCVA increased from 1.23±0.4 logMAR to 0.26±0.2 logMAR at final follow-up (P<0.001). Postoperative mean spherical equivalent refractive error and refractive and keratometric astigmatism were -3.41±3.1 D, 3.07±2.4 D, and 3.64±2.2 D, respectively. Bared DM was achieved in 86 (82.7%) eyes. Main complications encountered included filamentary keratitis (19.2%), non-endothelial graft rejection (14.4%), and suture abscess (10.6%). CONCLUSION: DALK using the bigbubble technique appears to be a safe and effective procedure in patients with keratoconus.