Dr. Hoyos’s Step by Step Lamellar Corneal Graft Jairo E Hoyos, Eduardo Arenas
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History and Evolution of Lamellar Techniques in Corneal SurgeryCHAPTER 1

Eduardo Arenas
2
 
INTRODUCTION
Corneal transplantation has been performed each time with better success for more than a century. Being the cornea a tissue devoid of blood vessels the possibility of rejection is much less lower than with other tissues or organ transplants such as kidney, liver, heart, etc. With the improvement in donor preservation, today it is possible to assume that 95 percent of the corneal grafts performed throughout the world will end in a transparent cornea. However there are still some late complications with a clear graft, mainly because the amount of irregularity of the wound and the risk of corneal displacement even many years after a successful surgery, sometimes requiring refitting contact lenses or submitting the patient to anastigmatic surgical procedures. High astigmatism has become the major cause of functional failure for a transparent keratoplasty.1, 2
Penetrating keratoplasty technique is still preferred by most surgeons and is more popular than lamellar techniques. This preference could be the result of comparative results showing less early visual recovery in lamellar techniques, because of the presence of irregularities in the interface and also for the increased technical difficulties and time consuming nature of this procedures.
The first successful graft was reported back in 1888 by von Hippel and was a lamellar technique.3 Later on Barraquer in 19514 Paufique in 1955, Brown5 in 1965 and Henderson6 in 1968, reported diverse results with 3different techniques. Lamellar procedures were aban doned because of reported worst posoperative visual acuity in comparison with penetrating techniques according to Richard and Paton in 1978.7, 8
Lamellar keratoplasty after the introduction of the concept of deep lamellar dissection by Malbran and others, diminishes the risk of irregularities in the interface and improves the visual prognosis in patients with keratoconus.9–12 In 1984 we introduced the concept of “air lamellar keratoplasty” which facilitates the identification of the pre-Descemet plane and diminish the risk of anterior chamber penetration and surface abnormalities.13 Different techniques to achieve a deeper dissection of the stroma and reaching the pre-Descemet level have also been described.14–16 Lately, several authors have shown that lamellar techniques when performed under the concept of deep lamellar dissection could achieve similar or better results with less complications than with the PK procedures.15–17 Sutureless corneal grafting has been advised for homoplastic lamellar keratoplasty using the microkeratome.18, 19
The concept of noninvasive lamellar techniques has also been applied to special corneal pathologies impossible to treat with penetrating grafts, as happens in peripheral corneal thinnings or perforations.20–23 The possibility of manipulation of only lamellar layers of the cornea was of course pioneered by Prof Jose Ignacio Barraquer and was the beginning of the new field of Refractive Surgery with all its modern advances.124
Lately, also searching a way to avoid the long postoperative follow-up and the complications of penetrating keratoplasty in cases with bullous keratopathy or endothelial corneal diseases Melles and Terry have introduced the concept of Deep Lamellar Posterior Keratoplasty as a revolutionary method to exchange only the posterior part of the cornea in such cases with promising results.24, 25
Our purpose with this book is to gather some of the experts in the lamellar approach to corneal surgery trying to explain step by step the details of these techniques and also the postoperative management, results and compli cations of each procedure. We hope that with this information the reader will have new tools and horizons for the surgical treatment of special corneal disorders with the modern concept of minimum invasive modern surgery.
REFERENCES
  1. Mushc DC, Meyer RF, Sugar A, Soong HK. Corneal astigmatism after penetrating keratoplasty. The role of suture technique. Ophthalmology 1989;96:698–703
  1. Lim N, Vogt U. Characteristics and functional outcomes of 130 patients with keratoconus attending a specialist contact lens clinic. Eye 2002;16:54–9
  1. Dhanda RP, Kalevar V. International Ophthalmology Clinics in Corneal Surgery 1972;12:7
  1. Barraquer J.I–La Queratoplastia Laminar anterior en el tratamiento del queratocono - Tesis Doctoral 1951
  1. Brown SL, Dohlman CH, Boruchoff SA. Dislocation of Descemet's membrane during keratoplasty. Am J Ophthalmol 1965;60:43–5
  1. 5 Henderson JW, Wolter JR. Separation of Descemet's membrane in keratoplasty. Am J Ophthalmol 1968;65:375–8
  1. Richard JM, Paton D, Gasset AR. A comparison of penetrating keratoplasty and lamellar keratoplasty in the surgical management of keratoconus. Am J Ophthalmol 1978;86:807–11
  1. Paton D. Lamellar keratoplasty, in Symposium on Medical and Surgical Diseases of the cornea. Transactions of the New Orleans Academy of Ophthalmology. CV Mosby C,  St Louis,  1980; p 406
  1. Malbrán E. Lamellar keratoplasty in keratoconus. The Cornea World Congress, DC. 1964. Edited by Jhon H. King and Jhon W. McTique. Butterworths,  Washinton, D.C.  1965
  1. Vasco-Posada J. Homoplastic interlaminar keratoplasty. Rev Soc Col Oftal 1973; 4:99
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  1. Amayem AF, Anwar M. Fluid lamellar keratoplasty in keratoconus. Ophthalmology 2000;107:76–9
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  1. Panda A, Singh BLM Ray M,. et al. Deep lamellar keratoplasty versus penetrating keratoplasty for corneal lesions. Cornea 1999;18:172–5
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  1. 6 Hafezi F, Mrochen M, Fankhauser F, Seiler T. Anterior lamellar keratoplasty with a microkeratome: a method for managing complications after refractive surgery. J Refract Surg 2003;19:52–7
  1. Cameron JA. Results of lamellar crescentic resection for pellucid marginal corneal degeneration. Am J Ophthalmol 1992;15:113:296–302
  1. Bessant DA, Dart JK. Lamellar keratoplasty in the management of inflammatory corneal ulceration and perforation. Eye 1994;8:22–8
  1. Soong HK, Farjo AA, Katz D, Meyer RF, Sugar A. Lamellar corneal patch grafts in the management of corneal melting. Cornea 2000;19:126–34
  1. Javadi MA, Karimian F, Hosseinzadeh A, Noroozizadeh HM, Sa'eedifar MR, Rabie HM. Lamellar crescentic resection for pellucid marginal corneal degeneration. J Refract Surg 2004;20:162–5
  1. Melles GR, Eggink FA, Lander F, Pels E, Rietveld FJ, Beekhuis WH, Binder PS. A surgical technique for posterior lamellar keratoplasty. Cornea 1998;17:618–26
  1. Terry MA, Ousley PJ. Endothelial replacement without surface corneal incisions or sutures: topography of the deep lamellar endothelial keratoplasty procedure. Cornea 2001;20:14–8