ABSTRACT
We present a case of a 31-year-old male with a past ocular history significant for keratoconus in both eyes, who underwent Deep Anterior Lamellar Keratoplasty (DALK) for his left eye and experienced graft-host interface neovascularization and interface hemorrhage as a complication. He was treated initially with removal of sutures and optimization of the ocular surface followed by subconjunctival bevacizumab, which subsequently improved his hemorrhage and neovascularization.
Subject(s)
Corneal Transplantation , Keratoconus , Male , Humans , Adult , Keratoplasty, Penetrating , Cornea/surgery , Keratoconus/complications , Keratoconus/diagnosis , Keratoconus/surgery , Bevacizumab , Neovascularization, Pathologic , Corneal Transplantation/adverse effects , Retrospective Studies , Treatment OutcomeABSTRACT
PURPOSE: To compare the visual and refractive outcomes and anterior segment optical coherence tomography (AS-OCT) findings of 2 different deep anterior lamellar keratoplasty (DALK) techniques in the treatment of advanced keratoconus with and without successful big bubble formation. METHODS: In this retrospective comparative case series, data from 79 consecutive eyes of 69 patients who underwent either big bubble (group 1, n: 62) or manual DALK (group 2, n: 17) were analyzed. The visual and refractive results, keratometric values and residual stromal thickness were assessed. Patients were seen at 1, 3, 6 and 12 months after the procedure and 1 month after complete suture removal. RESULTS: A big bubble was successfully obtained in 62 eyes (78.5%; group 1) and manual dissection was performed in the 17 remaining eyes (21.5%; group 2). The final best spectacle-corrected visual acuity (BSCVA) was 0.38 logMAR and 0.55 logMAR in Group 1 and 2, respectively (P<0.05). At the final visit, BSCVA≤0.30 logMAR was achieved in 80% and 60.8% of eyes in Groups 1 and 2, respectively (P<0.001). Groups 1 and 2 were comparable in terms of mean keratometry: 47.80D±2.81D (range, 41.30D to 54.2D) versus 45.90D±3.62D (range, 41.10D to 53.8 D), respectively; (P=0.56) and keratometric astigmatism: 3.81D± 2.1D (range, 1.0D to 6.20D) versus 3.56D±1.92D (range 1.2D to 6.85D), respectively; (P=0.40) at the final follow-up. The mean residual stromal thickness was 36.90±17.80µm in group 2. CONCLUSION: The presence of residual posterior corneal stroma when big bubble formation is not successfully achieved in DALK is correlated with lower postoperative visual acuity.
Subject(s)
Corneal Transplantation/methods , Keratoconus/diagnosis , Keratoconus/surgery , Adult , Case-Control Studies , Cornea/surgery , Corneal Topography , Corneal Transplantation/adverse effects , Descemet Membrane/surgery , Endothelium, Corneal/surgery , Female , Follow-Up Studies , Humans , Keratoplasty, Penetrating/adverse effects , Keratoplasty, Penetrating/methods , Male , Refraction, Ocular/physiology , Retrospective Studies , Tomography, Optical Coherence , Treatment Outcome , Turkey , Visual Acuity/physiology , Young AdultABSTRACT
The management of severe keratoconus requires corneal transplantation, for which the gold standard is deep anterior lamellar keratoplasty (DALK), preserving the healthy Descemet's membrane and endothelium. The safety and reproducibility of corneal cuts have been improved by the evolution of femtosecond lasers in refractive surgery, and femtosecond laser in DALK would seem to provide the same advantages over the manual method. In our retrospective study, we compare functional and anatomical results of femtosecond assisted DALK versus manual trephination DALK in patients with keratoconus in stage 4 of the Krumeich classification. It is a retrospective study including all patients with stage 4 keratoconus who underwent femtosecond laser assisted DALK between November 2012 and November 2015 in Nantes hospital. We compared those patients to a group of patients who underwent manual DALK in the same period, paired by age and maximal keratometry. We assessed visual acuity, pachymetry, endothelial cell density (specular microscopy), and keratometry before surgery and at 4, 8 and 12 months of follow-up. Laser settings and intraoperative complications were recorded. Nineteen patients underwent surgery by femtosecond assisted DALK, 6 women and 12 men with average age 30.2±10.8 years at transplantation. They were paired with a group of 17 patients who underwent manual DALK in order to compare results. Before surgery, mean visual acuity in the femtosecond group was 0.90 logMAR versus 0.89 logMAR in the manual group, showing no statistically significant difference (P=0.96). Both groups were similar in terms of preoperative age, mean keratometry, pachymetry and endothelial cell density. Average visual acuity post-surgery was 0.27, 0.26; and 0.14 logMAR for femtosecond DALK versus 0.27, 0.17 et 0.25 for manual DALK at 4, 8 and 12 months follow-up, respectively showing no statistically significant difference. After surgery, at 4, 8 and 12 months, mean pachymetry was similar in both groups, and average endothelial cell density was 2390 cells/mm2 in femtoDALK versus 2531 cells/mm2 in manual DALK at 12 months of follow-up, showing no statistically significant difference (P=0.5726). The rate of Descemet's membrane microperforations during the procedure was low and similar for both groups. Our study allows for a 12 month follow-up, with assessment of visual recovery, anatomical result and endothelial safety in a sample of 19 femtosecond laser assisted DALK with no statistical significant difference versus the manual trephination group. Femtosecond laser allows for increased reproducibility of the DALK procedure without reducing adverse effects during surgery. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. A medical economics study would be necessary to determine the cost effectiveness of femtosecond laser assisted DALK.