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Chapter-11 Divide and Conquer Technique for Deep Lamellar Keratoplasty

BOOK TITLE: Surgical Techniques in Anterior and Posterior Lamellar Corneal Surgery

Author
1. Tsubota Kazuo
2. Shimmura Shigeto
ISBN
9788180616051
DOI
10.5005/jp/books/10883_11
Edition
1/e
Publishing Year
2006
Pages
4
Author Affiliations
1. Keio University School of Medicine, Tokyo, Japan, Visiting Professor, Department of Ophthalmology, Tokyo Dental College, Chiba, Japan, Tokyo Dental College, Chiba, Japan, Keio University School of Medicine, Tokyo, Japan
2. Keio University School of Medicine, Tokyo, Japan
Chapter keywords

Abstract

The key to successful deep lamellar keratoplasty (DLKP) is the removal of stroma overlying the Descemet’s membrane (DM). Several techniques have been reported to show ways to expose the DM. Original techniques for removing stroma include layer-by-layer excision, hydration of the stroma, air injection into the stroma, and a one-step removal of DM using the mirror reflex created by air in the anterior chamber as a guide. All methods require excising stromal tissue from the stromal bed, which can risk rupturing DM when the remaining stroma is thin. Tears or breaks in DM usually occur due to direct puncture by surgical tools, or by shear stress due to mechanical stress. Mechanical stress occurs when excessive tension is applied to the stroma-DM junction, especially when handling tissue in quadrants blinded by the surgeons’ hands or stromal tissue. The “divide and conquer” (D and C) technique for DLKP is an analogy to the original divide and conquer technique devised for phacoemulsification surgery. Divide and conquer technique for cataract surgery was a major step in the advancement of phacoemulsification both in terms of surgical safety and surgery time. The technique provided standardized steps in the emulsification of cataract nuclei of different stages of nuclear sclerosis. The main objective for D and C in DLKP is to maintain a clear view of the surgical field during lamellar excision of the stroma. By dissecting the host cornea into several quadrants, lamellar excision of the stroma can be done under direct visualization of the incision edge as well as the stromal bed.

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