Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus.

PURPOSE: To report clinical outcomes of deep anterior lamellar keratoplasty (DALK) using the big-bubble technique in patients with keratoconus. DESIGN: Prospective noncomparative interventional study. SETTING: Single hospital. PATIENTS: Eighty-one unselected consecutive patients with moderate to advanced keratoconus intolerant to contact lenses and with poor spectacle-corrected visual acuity. INTERVENTION: DALK big-bubble technique. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, corneal topography, and endothelial cell density. RESULTS: Seventy-eight procedures (96%) were completed as DALK. Big-bubble was achieved in 50 cases (64%); 28 (36%) required manual intrastromal dissection. Intraoperative microperforations occurred in 11 cases (13%). Baseline mean uncorrected visual acuity was 20/500 and 20/60 two years after surgery. Average preoperative BSCVA, was 20/100 and 20/30 at the end of follow-up. Final BSCVA was better in patients in whom big-bubble with exposure of the Descemet membrane was achieved (P < .05). Average keratometry and SD (standard deviation) refraction changed from 62.1 +/- 6.7 diopters and -10.76 +/- 5 diopters to 47.51 +/- 4.73 diopters and -1.81 +/- 3.2 diopters, respectively after surgery. Mean preoperative endothelial cell density was 2202.29 +/- 392.35 cells/mm(2) and 2034 +/- 438.39 cells/mm(2) two years after surgery. Two patients developed stromal rejection. CONCLUSIONS: The DALK big-bubble technique is a valuable treatment in patients with keratoconus. Visual outcome is comparable to standard penetrating keratoplasty (PK) when formation of big-bubble with exposure of the Descemet membrane (DM) was achieved. Clinically important graft-host interface developed in some cases after manual intrastromal dissection. Stromal rejection is a rare complication.

Simple test to confirm cleavage with air between Descemet's membrane and stroma during big-bubble deep anterior lamellar keratoplasty.

We describe a simple test to confirm big-bubble formation in deep anterior lamellar keratoplasty by observing the position and movements of small air bubbles injected into the anterior chamber through a limbal paracentesis. The test also allows evaluation of the extension of Descemet's membrane cleavage from the posterior stroma relative to the margins of the corneal trephination.

Candida albicans interface infection after deep anterior lamellar keratoplasty.

PURPOSE: To report a case of interface infection by Candida albicans after deep anterior lamellar keratoplasty (DALK). METHODS: A 30-year-old man with keratoconus underwent DALK. Four weeks after surgery, the patient developed multiple infiltrates in the graft-host interface with absence of intraocular infection. Donor rim cultures grew C. albicans. Penetrating keratoplasty (PK) was performed because of worsening of the infection despite topical, local, and systemic antifungal therapy. RESULTS: Cultures carried out on the excised donor cornea confirmed donor-to-host transmission of C. albicans. An aqueous tap taken before PK was negative. Six months after PK, the corneal graft was clear with no recurrence of infection. CONCLUSIONS: After DALK, in cases of donor graft microbial contamination, infection may develop at the graft-host interface. This may delay or prevent direct intraocular penetration of microorganisms, reducing the risk of development of endophthalmitis. PK may be needed to eradicate the infection in cases where conservative treatment fails.

Favourable response to infliximab in a case of bilateral refractory Mooren's ulcer.

A woman with progressive bilateral Mooren's ulcer developed recurrent corneal perforations and melting requiring tectonic grafts, despite conventional immunosuppressant therapy. Following treatment with infliximab, an anti-tumour necrosis factor agent, the patient showed marked reduction in conjunctival inflammation and no further recurrence of corneal thinning and perforation during 2-year follow up on maintaining treatment.

Long-term clinical outcomes of deep anterior lamellar keratoplasty in patients with keratoconus.

PURPOSE: To report long-term clinical outcomes of deep anterior lamellar keratoplasty (DALK) in patients with keratoconus. DESIGN: Retrospective noncomparative interventional study. METHODS: setting: Single center. patients: Total of 158 eyes/150 consecutive patients with keratoconus with postoperative follow-up time equal to or greater than 4 years. intervention: DALK. main outcome measure(s): Uncorrected and corrected distance visual acuity (UDVA, CDVA), mean refractive spherical equivalent (MRSE), keratometry, endothelial cell density (ECD). RESULTS: Mean postoperative follow-up was 76.9 ± 23.2 (range 48-120) months. Preoperative UDVA was 20/400 (1.5 ± 0.4 logMAR), CDVA 20/50 (0.7 ± 0.2 logMAR), MRSE -11.1 ± 5.6 diopters (D), mean keratometry 60.7 ± 6.1 D, topographic astigmatism 4.7 ± 2.6 D. At last postoperative follow-up visit, UDVA improved to 20/50 (0.5 ± 0.3 logMAR), CDVA to 20/25 (0.09 ± 0.1 logMAR), MRSE to -2.6 ± 3.5 D, mean keratometry to 44.4 ± 2.2 D, and topographic astigmatism to 2.9 ± 1.3 D. Postoperative ECD did not vary from preoperative values being 2070.5 ± 367.5 cell/mm(2) and 2198 ± 373 cell/mm(2), respectively, with 70% of eyes (111/158) showing ECD ≥2000 cells/mm(2). Eighteen eyes (11.3 %) developed stromal or epithelial rejection, 3 (1.8%) required regrafting. Eyes with successful big bubble showed greater CDVA than those that required manual dissection at follow-up equal to or less than 5 years but comparable results in the longer term. CONCLUSIONS: DALK provides stable long-term visual and refractive outcomes. Risk of graft rejection, postoperative complication, and late ECD decay is reduced when compared to standard penetrating keratoplasty.

Influence of graft-host interface on the quality of vision after deep anterior lamellar keratoplasty in patients with keratoconus.

PURPOSE: To investigate the influence of graft­host interface on the quality of vision after deep anterior lamellar keratoplasty (DALK). METHODS: Retrospective, nonrandomized, comparative case series. Sixty patients (60 eyes) with advanced keratoconus underwent DALK using the big-bubble technique. Twenty-eight patients had complete stromal excision with Descemet membrane (DM) exposure[DALK with DM baring (DM-DALK)], whereas in 32 cases, a layer of stroma was left adherent to the recipient DM [DALK without DM baring (pre-DM-DALK)]. Twenty-two patients with keratoconus (22 eyes) who underwent penetrating keratoplasty (PK) were chosen for comparison. Main outcome measures were uncorrected visual acuity, best spectacle-corrected visual acuity, low-contrast visual acuity(LCVA), and Pelli-Robson contrast sensitivity. RESULTS: Uncorrected visual acuity was equal in the 3 groups. Median best spectacle­corrected visual acuity was 0.1 logarithm of the minimum angle of resolution (logMAR) in the PK group, compared with 0.06 logMAR in the DM-DALK group (P = 0.66) and 0.12 logMAR in the pre-DM-DALK group (P = 0.016). Pre-DM-DALK patients exhibited worse LCVA than PK (P = 0.029) and DM-DALK patients (P = 0.022), whereas PK and DM-DALK patients showed comparable LCVA (P = 0.974). Pelli-Robson contrast sensitivity was equivalent in PK and DM-DALK groups (P = 0.408) and greater in DM-DALK group than in pre-DM-DALK group (P = 0.038). CONCLUSIONS: In selected patients, quality of vision after DALK was comparable to that after PK when stromal excision was extended to the DM and inferior to vision after PK when layers of stroma were left adherent to the DM. Advances in DALK technique are required to allow easier and repeatable baring of the DM.

Deep anterior lamellar keratoplasty after Intacs implantation in patients with keratoconus.

PURPOSE: To evaluate the clinical outcomes of deep anterior lamellar keratoplasty (DALK) in patients with unsatisfactory vision after intrastromal corneal ring segment (ICRS) implantation for keratoconus refractive correction. METHODS: Prospective interventional case series. Five patients with consecutive keratoconus and poor visual outcome after ICRS implantation underwent DALK Big bubble technique. Three patients had ICRS explanted several months before lamellar graft surgery because of late postoperative complications; the other 2 had ring segments in place at the time of DALK. RESULTS: Average preoperative logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity was 1.5 +/- 0.685 (20/800) and 0.74 +/- 0.427 (20/114) at the end of the follow-up. Mean preoperative logMAR best-corrected visual acuity was 0.56 +/- 0.089 (20/70) and 0.12 +/- 0.044 (20/25) at the last examination. Mean MRSE changed from -8.75 +/- 6.74 diopters (D) preoperatively to -3.35 +/- 2.302 D postoperatively. Mean topographic astigmatism and mean topographic keratometry (K) varied from 3.96 +/- 2.197 and 50.06 +/- 3.965 D preoperatively to 1.72 +/- 1.147 and 42.34 +/- 2.356 D postoperatively, respectively. No operative complications occurred. One patient developed stromal rejection that regressed after topical steroid therapy. CONCLUSIONS: DALK may be proposed in alternative to penetrating keratoplasty for the treatment of patients with keratoconus with poor visual result after ICRS implantation. DALK Big bubble technique may be carried out with ICRS in place. Visual and refractive outcomes are comparable with standard penetrating keratoplasty in patients with keratoconus.

Choroidal effusion after diode laser cyclophotocoagulation in Sturge-Weber syndrome.

Sturge-Weber syndrome is complicated by glaucoma in 30% of patients; of these, 60% develop glaucoma in infancy and 40%, in childhood. Medical treatment often fails to adequately control IOP in these patients, and surgical intervention is frequently necessary. Filtration surgery may be complicated by expulsive choroidal hemorrhage and massive choroidal effusion, more often in patients with Sturge-Weber syndrome compared with other patients presenting with glaucoma, particularly in eyes with choroidal hemangioma, because the rapid decrease in IOP during surgery may induce the transudation of fluid from a fragile vessel in the choroidal hemangioma, leading to the development of choroidal effusion. When the risk of drainage surgery is considered too high, diode laser cyclophotocoagulation may, in theory, be a safer treatment to lower the IOP. Our case illustrates that significant but transient choroidal effusions can still occur after diode laser procedure.