Editors Vishal Jhanji MD
Assistant Professor of Ophthalmology Cornea and External Eye Diseases The Chinese University of Hong Kong
Hong Kong
Namrata Sharma MD DNB MNAMS
Additional Professor of Ophthalmology Cornea and Refractive Surgery Services Dr Rajendra Prasad Center for Ophthalmic Sciences All India Institute of Medical Sciences
New Delhi, India
Rasik B Vajpayee MS FRCS (Edin) FRANZCO
Professor of Ophthalmology Head, Cornea and Refractive Surgery Services Dr Rajendra Prasad Center for Ophthalmic Sciences All India Institute of Medical Sciences
New Delhi, India
Center for Eye Research Australia University of Melbourne
Melbourne, Australia
ForewordMassimo Busin
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Deep Anterior Lamellar Keratoplasty: Different Strokes
First Edition: 2012
9789350256329
Printed at
5Contributors
- Anasua Ganguly mbbs
- Junior Resident
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences
- New Delhi, India
- Donald TH Tan md frcs(ed)
- Professor of Ophthalmology
- Singapore National Eye Center
- 11 Third Hospital Avenue
- Singapore 168751
- Department of Ophthalmology
- Yong Loo Lin School of Medicine
- National University of Singapore
- Singapore 117597
- Elsie Chan
- Consultant
- Royal Victorian Eye and Ear Hospital
- Melbourne, VIC
- Australia
- Fred Eggink od
- Netherlands Institute for Innovative Ocular Surgery
- Rotterdam, The Netherlands
- Gerrit RJ Melles md
- Netherlands Institute for Innovative Ocular Surgery
- Consultancy for Research and Development of Ophthalmic Surgical Techniques
- Rotterdam, The Netherlands
- Himanshu Shekhar md
- Senior Resident
- Cornea and Refractive Surgery Services
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences
- New Delhi, India
- Jacqueline Beltz mbbs franzco
- Consultant
- Royal Victorian Eye and Ear Hospital
- Melbourne, VIC
- Australia
- Jaya Gupta md
- Senior Research Associate
- Cornea and Refractive Surgery Services
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences
- New Delhi, India
- Jodhbir S Mehta bsc (hons.) mbbs mrcophth frcophth frcs (ed)
- Associate Professor
- Singapore National Eye Center
- 11 Third Hospital Avenue, Singapore 168751
- Assistant Director (Clinical Trials)
- Singapore Eye Research Institute
- Head, Tissue Engineering and Stem Cells Group
- Singapore Eye Research Institute
- Duke-NUS Graduate Medical School
- Adj Associate Professor, Dept of Ophthalmology
- Yong Loo Lin School of Medicine, NUS
- Luigi Fontana md phd
- Unità Operativa di Oculistica
- Ospedale Maggiore, Bologna, Italy
- Mohammad Anwar frcs (edin), frcopth
- Senior Consultant Ophthalmic Surgeon
- Cornea and External Disease
- Magrabi Eye Hospital
- Dubai, UAE
- Namrata Sharma md dnb mnams
- Additional Professor of Ophthalmology
- Cornea and Refractive Surgery Services
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences
- New Delhi, India
- Prafulla K Maharana md
- Senior Resident
- Cornea and Refractive Surgery Services
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences
- New Delhi, India
- Rajesh Fogla dnb frcs (edin) mmed
- Apollo Hospitals
- Jubilee Hills
- Hyderabad, Andhra Pradesh, India
- Rasik B Vajpayee ms frcs (edin) franzco
- Professor of Ophthalmology
- Head, Cornea and Refractive Surgery Services
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences, New Delhi
- Center for Eye Research Australia
- University of Melbourne, Melbourne, Australia
- Rishi Swarup mbbs frcs
- Consultant, Cornea and Anterior Segment Services
- LV Prasad Eye Institute
- Hyderabad, Andhra Pradesh, India
- Sri Vatsa Sehra mbbs
- Junior Resident
- Cornea and Refractive Surgery Services
- Dr Rajendra Prasad Center for Ophthalmic Sciences
- All India Institute of Medical Sciences
- New Delhi, India
- Vishal Jhanji md
- Assistant Professor of Ophthalmology
- Cornea and External Eye Diseases
- The Chinese University of Hong Kong
- Hong Kong
During the second half of the 20th century penetrating keratoplasty has become the gold therapeutic standard for corneal stromal diseases, while lamellar keratoplasty was performed only rarely. Instead, over the last decade several factors have brought anterior lamellar keratoplasty to the forefront again. On one hand, the results of penetrating keratoplasty were far from being optimal, with a time necessary for visual rehabilitation usually longer than a year and a final postoperative vision often negatively affected by high-degree astigmatism, most of the times also of the irregular type. On the other hand, most importantly, the unnecessary substitution of the recipient endothelial layer through a full-thickness corneal transplantation has caused in a relatively high number of patients immunologic rejection episodes against the donor endothelium, possibly leading to graft failure.
Anterior lamellar keratoplasty offers several advantages over penetrating keratoplasty. First of all, as the recipient Descemet's membrane and endothelium with or without a thin layer of deep stroma are left in place, the procedure is practically extraocular, and major intraoperative complications, such as expulsive hemorrhage or intraocular infections can be avoided.
Another consequence is that obviously no endothelial failure can be expected through an immunologic rejection. Stromal or epithelial immunologic rejections can still be seen, although rarely, but are self-limited and respond promptly to steroidal treatment. As a result, steroids are usually given at lower doses and for a shorter period of time during the postoperative course, thus substantially reducing the risk of side effects, such as secondary glaucoma or cataract formation.
Finally, corneal tissue need not be viable for good results with anterior lamellar keratoplasty. Even eyebank tissue that is out-of-date, or corneal tissue frozen and preserved at −70° C could be used for this purpose. As a result, distribution of different types of donor tissue can be optimized and more grafts made available for full-thickness or posterior lamellar keratoplasty.
Nowadays, anterior lamellar keratoplasty includes a variety of techniques, which are different from those most ophthalmologists were originally taught. They are all brilliantly illustrated in this book by some of those who have invented them and some of those who have contributed to their refinement and popularization. All chapters are authoritative, based on great practical experience and bespeak the authors' background as teachers as well as surgeons. I think this book is an important tool for any ophthalmic surgeon, who approaches the new world of anterior lamellar keratoplasty, as it is now and will be in the future.
Massimo Busin md
Professor of Ophthalmology
Head, Ophthalmology Department
"Villa Igea" Private Hospital
Forlì, Italy
9Preface
Corneal transplantation surgery is the most commonly performed organ transplantation in the world. Taking into consideration over one hundred years of history, the scale of continuous development in a bid to achieve perfection in this surgery is exciting. In the last decade the major focus has been on the question ‘to laminate or penetrate?’ Clearly, lamellar corneal surgeries are emerging as the leader.
Arthur von Hippel reported the first partially successful lamellar graft in 1886. In the first half of the twentieth century, optical lamellar keratoplasty was a tedious procedure which did not yield optimal results postoperatively. In the more recent times, the approach is to achieve the deepest possible interface with posterior layer of uniform thickness. These guidelines have served as the benchmark for the evolution of lamellar grafting techniques over the last 25 years.
Deep anterior lamellar keratoplasty (DALK) has garnered immense popularity in recent times. Corneal surgeons around the globe have fostered careful and precise development of this challenging yet exciting surgical maneuver. It is a promising technique, but the procedure is difficult and may not be reproducible in the hands of average corneal transplant surgeon.
The "different strokes" in DALK include the conventional Melles and the "Big bubble" technique and also the newer modifications such as "Double bubble" technique, cannula-assisted DALK, groove and peel technique as well as diamond blade-guided DALK. The different types of modifications presented by eminent lamellar corneal transplant surgeons from all over the world, in this book are an endeavor to make DALK feasible by all corneal transplant surgeons.
Vishal Jhanji
Namrata Sharma
Rasik B Vajpayee