Preliminary Pages

1Step by Step Anterior and Posterior Lamellar Keratoplasty2

3Step by Step Anterior and Posterior Lamellar Keratoplasty

Editor Thomas John MD Clinical Associate Professor Loyola University at Chicago, Maywood, Illinois, USA Cornea Institute of Illinois and Indiana Tinley Park and Oak Lawn, Illinois, Merrillville, Indiana, USA Chicago Cornea Research Center, Tinley Park, Illinois, USA Foreword Kenneth R Kenyon

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Step by Step Anterior and Posterior Lamellar Keratoplasty

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher.

First Edition: 2006

9788180617577

Typeset at JPBMP typesetting unit

Printed at Paras Press

5CONTRIBUTORS

	Thomas John, md Clinical Associate Professor Loyola University at Chicago Maywood, Illinois, USA Cornea Institute of Illinois and Indiana Tinley Park and Oak Lawn, Illinois Merriville, Indiana, USA Chicago Cornea Research Center Tinley Park, Illinois, USA Chapters 1, 6, 9, 15 DVD Video 4, 6, 7
	Enrique S Malbran, md Medical Director Clinica Oftalmologica Malbran Buenos Aires, Argentina Chapter 1
	Mohammed Anwar, md Chief of Cornea Unit El Magrabi Specialist Hospital Jeddah Kingdom of Saudi Arabia Chapter 2
	Klaus D Teichmann, md Chief Anterior Segment Division King Khaled Eye Specialist Hospital Riyadh, Kingdom of Saudi Arabia Chapter 2 DVD Video 16
	Juntaro Sugita, md Vice President Sugita Eye Hospital Nagoya, Japan Chapter 3 DVD Video 2
	Kazuo Tsubota, md Professor and Chairperson, Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan, Visiting Professor, Department of Ophthalmology, Tokyo Dental College, Chiba, Japan Chapter 4
	Shigeto Shimmura, md Assistant Professor Department of Ophthalmology Keio University School of Medicine Tokyo, Japan Chapters 4, 11 DVD Video 3
	Weldon W Haw, md Clinical Assistant Professor of Ophthalmology, Cornea and Refractive Surgery, Department of Ophthalmology, UCSD School of Medicine, and Shiley Eye Center, Chief of Ophthalmology, San Diego VA Health Services, San Diego, CA, USA Chapter 5
	Edward E Manche, md Associate Professor and Director of Cornea and Refractive Surgery, Stanford University School of Medicine, Stanford, CA, USA Chapter 57
	Massimo Busin, md Professor of Ophthalmology University of Bonn, Germany Professor of Ophthalmology Louisiana State University, New Orleans Louisiana, USA Professor of Ophthalmology Director Department of Ophthalmology “Villa Serena” Hospital, Forlì, Italy Chapter 7 DVD Video 5
	Mark A Terry, md Director Corneal Services Devers Eye Institute, Scientific Director Lions Vision Research Laboratory of Oregon, Clinical Associate Professor Oregon Health Sciences University Portland, Oregon, USA Chapter 8
	Paula J Ousley, md Research Director Lions Vision Research Laboratory of Oregon Portland, Oregon, USA Chapter 8
	Kathleen McClellan, md Senior Lecturer Save Sight Institute University of Sydney, NSW, Australia, Department of Ophthalmology and Save Sight Institute University of Sydney and Sydney Eye Hospital, Sydney, Australia Chapter 108
	Behrooz Golchin, md Consultant Ophthalmic Surgeon Mater Hospital, Belfast Northern Ireland Department of Ophthalmology and Save Sight Institute University of Sydney and Sydney Eye Hospital, Sydney, Australia Chapter 10
	Thomas KH Butler, md Department of Ophthalmology and Save Sight Institute, University of Sydney and Sydney Eye Hospital, Sydney, Australia; Consultant Ophthalmologist Great Yarmouth, Norfolk United Kingdom Chapter 10
	AW Wechsler, md Visiting Medical Officer Sydney Eye Hospital, NSW Australia Department of Ophthalmology and Save Sight Institute, University of Sydney and Sydney Eye Hospital Sydney, Australia Chapter 10
	Con Petsoglou, md Lecturer Discipline of Clinical Ophthalmology and Eye Health, Save Sight Institute, University of Sydney and Sydney Eye Hospital, Sydney, Australia Chapter 109
	Gerard Sutton, MD Senior Staff Specialist Sydney Eye Hospital NSW, Australia Department of Ophthalmology and Save Sight Institute University of Sydney and Sydney Eye Hospital, Sydney, Australia Chapter 10
	David IM Robinson, md Ophthalmologist Sydney Laser and Vision Centre, NSW, Australia; Department of Ophthalmology and Save Sight Institute, University of Sydney and Sydney Eye Hospital, Sydney, Australia Chapter 10
	Lyon P Robinson, md Visiting Medical Officer Sydney Eye Hospital NSW, Australia Department of Ophthalmology and Save Sight Institute, University of Sydney and Sydney Eye Hospital, Sydney, Australia Chapter 10
	Tae-Won Hahn, md Director of Apgujong St. Mary's Eye Center Clinical Professor of Department of Ophthalmology, Catholic University Medical College, Seoul, Korea Chapter 1210
	Jae-Ho Kim, md Director and Professor of 21C Eye Hospital at Injae University Medical School Seoul, Korea Chapter 12
	Karim Rasheed, MD Director Templeton Eye Center Templeton, California, USA Chapter 13
	George M Salib, md Attending, Private Practice De La Pena Eye Centers Los Angeles, California, USA Chapter 13
	Yaron S Rabinowitz, md Clinical Professor Department of Ophthalmology Jules Stein Eye Institute UCLA School of Medicine, Los Angeles, California, USA Director of Ophthalmology Research, Cedars-Sinai Medical Center, Los Angeles, California, USA; Director, Ocular Genetics Research Program, Cedars-Sinai Medical Center, Los Angeles, California, USA Chapter 13
	Leejee H Suh, md Resident in Ophthalmology Wilmer Eye Institute Johns Hopkins School of Medicine, Baltimore, Maryland, USA Chapter 1411
	Esen Karamursel Akpek, md Associate Professor of Ophthalmology Director Ocular Surface Diseases and Dry Eye Clinic The Wilmer Eye Institute Johns Hopkins School of Medicine Baltimore, Maryland, USA Chapter 14
	Walter J Stark, md Distinguished Professor of Ophthalmology Director of the Stark-Mosher Center for Cataract and Corneal Diseases Wilmer Eye Institute Johns Hopkins School of Medicine Baltimore, Maryland, USA Chapter 14

13FOREWORD

The Back to the Future movement for lamellar keratoplasty is in full swing, and as usual the drum keeping us on the beat is that of our own latter day cornea rocker, Thomas John!

Tom's capability as composer and director is all too evident in his magnum opus, “Surgical Techniques in Anterior and Posterior Lamellar Corneal Surgery,” a tome of truly Wagnerian proportions with written and video performances by nearly 100 notable corneal surgeons & scientists. Now for those with an eye and ear for lighter classics, comes the greatest hits and highlights version of “Step by Step Anterior and Posterior Lamellar Keratoplasty” as choreographed by player-coach-impresario John whose fancy footwork is exceeded only by his microsurgical handicraftmanship.

Having known Dr. John for more than two decades, I have derived special pleasure both in observing his professional and personal development as well as in taking the old mentor's pleasure of learning from one's students. Also being aware of Thomas' personal commitment to a multi-faceted and balanced life as embodied in his “report card of life” credo, it is self-evident that yet another honors grade is deserved for his virtuoso lamellar corneal surgery 14performances. Apart, above and beyond that, Tom is to, say the least, one Rolling Stone that gathers no moss!

Kenneth R Kenyon, md

Cornea Consultants International

Boston, USA & Munich, Germany

Eye Health Vision Centers, North Dartmouth, MA, USA

Schepens Eye Research Institute, and Harvard Medical School, Boston, MA, USA

15PREFACE

Step by Step Anterior and Posterior Lamellar Keratoplasty covers both anterior and posterior lamellar surgical techniques in a useful, concise, easy-to-carry around book.

Currently, there is a continued, rising tide of interest in lamellar corneal surgical procedures all over the world, that will ultimately find its way into every operating room dealing with corneal surgeries. This initial “tsunamic wave” of interest is expected to be followed by a second, third and more waves, that it is predicted to sweep the entire corneal surgical community over time. Such an optimistic prediction is based on the term that the editor has introduced, namely, “Selective Tissue Corneal Transplantation (STCT).” Why discard healthy, recipient corneal tissue along with the regionally diseased corneal tissue? Why remove and discard the entire cornea as in penetrating keratoplasty (PKP) when the diseased portion of the corneal tissue may be located in the front, middle, or back part of the patient's cornea?

Chapter 1 covers classification of lamellar corneal surgery. There are several overlapping terminologies in the published, peer-reviewed journals, many of which pertain to the same surgical procedure. Chapter 1 addresses terminologies, abbreviations, and definition of various terms as it relates to lamellar keratoplasty.16

Chapter 2 provides coverage of the popular “big-bubble” technique, where corneal intrastromal air is used to create a big air bubble within the cornea to assist the surgeon in performing deep anterior lamellar keratoplasty. Other important surgical techniques in performing anterior lamellar keratoplasty are covered. These include the use of fluid in chapter 3, divide and conquer technique in chapter 4, use of viscoelastic material in chapter 5, and a combination of dye such as indocyanine green and fluid in a pattern of forced hydrodissection technique to perform total anterior lamellar keratoplasty.

Although, mechanical lamellar surgical procedures have withstood the test of time, newer technological advances such as the modern microkeratome further facilitates and improves lamellar corneal surgery and takes it to the next level, by providing a superior corneal interface that will ultimately benefit the patient's visual outcome. Chapter 7 describes the use of microkeratome for lamellar keratoplasty.

Chapters 8 and 9, move the focus from anterior to posterior cornea, and cover the current advances in corneal endothelial surgery, namely, posterior lamellar keratoplasty (PLK). Chapter 8 describes deep lamellar endothelial keratoplasty (DLEK), while the next chapter describes descemetorhexis with endokeratoplasty (DXEK). Although, DLEK sparked new interest in otherwise dormant keratoplasty techniques, it demanded the creation of an intrastromal pocket without any perforations. With the introduction of DXEK, there is no longer a need to create the intrastromal pocket, which has been a welcome addition to the newer PLK techniques.17

Pterygium surgery is always of great interest to both general ophthalmologists and cornea specialists. Chapter 10 describes the use lamellar keratoplasty technique in the management of recurrent pterygium. Yet another important management issue facing ophthalmologists is the patient with a corneal perforation. Chapter 11 describes deep lamellar keratoplasty technique in the management of corneal perforation. Such a procedure may be more useful than performing a full-thickness PKP when the eye is inflamed.

Surgical management of Terrien's marginal degeneration, pellucid marginal degeneration and Mooren's ulcer are covered in chapters 12, 13, and 14 respectively. These are surgically challenging diseases and the authors present useful surgical techniques when dealing with these conditions.

Chapter 15 covers artificial anterior chambers (AAC). A good working knowledge of AAC is essential for any corneal surgeon who wishes to perform lamellar keratoplasty. The various AAC that are currently (at the time of writing) available are included.

This step by step approach to lamellar surgical procedures of the human cornea, will serve as a useful book for ophthalmic surgeons all over the world.

Thomas John

Chapter Notes