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Deep Anterior Lamellar Keratoplasty: Different Strokes
Rasik B Vajpayee, Namrata Sharma, Vishal Jhanji
1: EVOLUTION, ANATOMY AND PREOPERATIVE EVALUATION
1:
Evolution of Deep Anterior Lamellar Corneal Transplantation
History of Lamellar Corneal Transplantation
2:
Applied Anatomy and Physiology of Cornea
Precorneal Tear Film
Structure of Cornea
Epithelium
Superficial Squamous Cells
Middle Wing Cells
Deep Basal Cells
Basement Membrane
Bowman's Layer
Corneal Stroma
Descemet's Membrane
Endothelium
Innervation of the Cornea
Blood Supply
Oxygen and Nutritional Supply
Applied Physiology of Cornea
Differentiation of Anterior and Posterior Corneal Stroma
Corneal Transparency
Dissection Plane in Deep Anterior Lamellar Keratoplasty
Summary
3:
Indications of Deep Anterior Lamellar Keratoplasty
Introduction
Keratoconus
Pellucid Marginal Degeneration
Corneal Stromal Dystrophies
Granular Corneal Dystrophy
Lattice Corneal Dystrophy
Macular Corneal Dystrophy
Postrefractive Surgery Keratectasia
Corneal Scars
Corneal Clouding due to Mucopolysaccharidosis
Ocular Surface Disease
Descemetocele
DALK in Keratoconus in Healed Hydrops
Other Indications for Deep Lamellar Keratoplasty
4:
Preoperative Evaluation of the Recipient
Introduction
Systemic Evaluation
Ocular Examination
Visual Acuity
Lids/Adnexa/Tear Film Status
Slit lamp Examination
Fundus Evaluation
Preoperative Investigations
Tear Film Status
Corneal Curvature
Corneal Pachymetry
Corneal Imaging
Specular Microscopy
Summary
5:
Eye Banking Issues Related to Procurement of Donor Cornea
Introduction
Impact of DALK on Eye Banking
Tissue Criteria
Conclusion
2: SURGICAL TECHNIQUES FOR DEEP ANTERIOR LAMELLAR KERATOPLASTY
6:
Instruments for Deep Anterior Lamellar Keratoplasty
Instruments for Globe Exposure
Eye Speculum
Globe Supporting Rings
Corneal Marking Instruments
Corneal Trephines
Types of Trephines
Conventional Circular Trephines
Single Point Cutting Corneal Trephines
Combination Corneal Trephines
Non-contact Trephines
Lamellar Dissectors
Instruments for Donor Cornea Dissection
Gauze Piece Fixated Eyeball
Eye Globe Fixation
Tudor Thomas Stand
Cutting Blocks
Corneal Endothelial Punches
Cottingham Corneal Punch
Troutman Corneal Punch
IOWA PK Press Corneal Punch
Lieberman Gravity-action Punch
Rothman-Gilbard Corneal Punch
Cutting Instruments
Blade Breaker
Diamond Knife
Corneal Scissors
Grasping Instruments
Toothed Forceps
Non-toothed Forceps
Forceps with Special Functions
Holding Instruments
Sutures
Qualitative Keratometers
Acknowledgments
7:
Deep Anterior Lamellar Keratoplasty: Melles Technique
Optical Visualization of Dissection Depth During Surgery
Strategy to Minimize Interface Haze
Manual Deep Stromal Dissection through a Scleral Tunnel Incision
Viscodissection of Descemet's Membrane from the Stroma
Preparation of Donor Tissue
Suturing Technique
Perioperative Topical and Systemic Therapy
Rigid Gas Permeable Contact Lens Fitting
Results
Conclusion and Recommendations
Instruments
Acknowledgments
8:
Deep Anterior Lamellar Keratoplasty "The Big Bubble Technique"
Historical Background
Introduction
Indications
Contra-indications
Advantages
Limitations
Anesthetic Requirements
Pre-operative Topical Medications
Surgical Technique
Recipient Dissection
Post Keratectomy Big Bubble
The Hidden Big Bubble
Augmentation of the Big Bubble
Intra-Descemet's Membrane Big Bubble
Donor Dissection
Surgical Instruments
Post-op Medications
Follow up Schedule
Prevention of Complications
Management of Complications
Results
Conclusion
9:
"Double Bubble" Deep Anterior Lamellar Keratoplasty
Introduction
Principle of the Technique
Surgical Technique
Anesthesia
Technique
Suturing of the Donor Lenticule
Summary
10:
SNEC Technique of Deep Anterior Lamellar Keratoplasty
Manual Anterior Lamellar Keratoplasty
Open Manual Dissection
Closed Manual Dissection
Maximum Depth Deep Anterior Lamellar Keratoplasty (Md DALK)
Anwar's Big Bubble Technique
SNEC Modified Anwar Technique
11:
Cannula Assisted Big Bubble Deep Anterior Lamellar Keratoplasty
Introduction
Surgical Technique
Preoperative Evaluation
Anesthesia
Surgical Technique
Results
12:
"Groove and Peel" Deep Anterior Lamellar Keratoplasty
Introduction
Conventional Techniques of DALK
Surgical Technique
Discussion
13:
Safe Technique of Deep Anterior Lamellar Keratoplasty
Introduction
Big Bubble Technique Step-by-Step (Video 1)
Operative Complications during DALK BBT
Partial Thickness Trephination (Video 2)
Needle Insertion (Videos 3 and 4)
Air Injection (Video 5)
Big Bubble Slit (Video 6)
Stromal Excision (Video 7)
Donor Button Descemet's Membrane Stripping (Video 8)
Donor Suture
14:
Diamond Knife Assisted Deep Anterior Lamellar Keratoplasty
Introduction
Indications
Preoperative Work-up
Instruments Required
Surgical Technique
Patient Preparation
Marking
Intraoperative Pachymetry
Diamond Knife Assisted Incision
Lamellar Dissection
Donor Preparation
Cone Decompressing Incisions
Suturing
Postoperative Management
Suture Removal
Postoperative Follow-up
Complications
Intraoperative
Postoperative
Results
15:
Deep Anterior Lamellar Keratoplasty for Descemetoceles and Corneal Perforations
Deep Anterior Lamellar Keratoplasty for Descemetoceles
Indication
Contraindications
Advantages of DALK over Penetrating Keratoplasty
Preoperative Evaluation
Surgical Technique
Anesthesia
A. Host Bed Preparation
B. Donor Preparation
Modifications of Surgical Technique of DALK in Descemetoceles
Postoperative Medications
Follow-up
Complications
Precautions
Management
Results
Deep Anterior Lamellar Keratoplasty for Corneal Perforations
Conclusion
3: COMPLICATIONS, OUTCOMES AND FUTURE
16:
Postoperative Regime Evaluation and Follow-up
Postoperative Treatment Regime
Follow-up Visits
Postoperative Parameters
Visual Acuity
Contrast Sensitivity and Glare
Slit Lamp Examination
Corneal Pachymetry
Corneal Topography
Specular Microscopy
Suture Removal
Summary
17:
Intraoperative Complications and Management
Intraoperative Complications
Full-thickness Corneal Trephination
Perforation of DM with Needle
Failure of Formation of Big Bubble
Perforation of DM
Layer by Layer Lamellar Keratoplasty
Use of Small Air Bubble to Aid in Reaching the Level of Descemet's Membrane
Conversion of DALK to PKP
18:
Postoperative Complications
19:
Outcomes of Deep Anterior Lamellar Keratoplasty
Introduction
Deep Anterior Lamellar Keratoplasty vs Penetrating Keratoplasty
Postoperative Visual Acuity
Endothelial Cell Count
Stromal Graft Rejection
Contrast Sensitivity and Corneal Sensations
Conclusion
20:
Future of Deep Anterior Lamellar Keratoplasty
INDEX
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Index
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