Zusammenfassung
Ziel
Es werden unterschiedliche, für die Behandlung von Hornhautendothelstörungen in Frage kommende Techniken der posterioren lamellären Keratoplastik über einen skleralen Zugang beschrieben.
Methode
Drei Techniken wurden entwickelt: 1. Sklerainzision von 9,0 mm, über die ein intrakornealer Trepan und eine löffelförmige Führungsschiene eingeführt werden. Anschließend wird eine posteriore Spenderhornhautscheibe in die Vorderkammer eingebracht. 2. Eine 5 mm breite Tunnelinzision der Sklera unter Anwendung von Mikroscheren und mit Faltung der posterioren Spenderhornhautscheibe vor dem Einbringen. 3. Tunnelinzision von 4,0 mm, über die eine Descemetorhexis der Wirtshornhaut vorgenommen wird.
Ergebnisse
Bei Patienten ohne sonstige Augenerkrankung betrug die beste brillenkorrigierte Sehschärfe jeweils 0,7–1,0 und der Astigmatismus im Mittel 2,1 dpt. Die Endothelzellzahlen lagen nach 6 Monaten bei 2.126 Zellen/mm2, nach 36 Monaten bei 1.137 Zellen/mm2.
Schlussfolgerung
Die posteriore lamelläre Keratoplastik ist eine Erfolg versprechende Operationstechnik für Hornhautendothelstörungen. Die Transparenz des Transplantats bleibt über 5 Jahre nach dem operativen Eingriff stabil.
Abstract
Purpose
To describe several techniques for posterior lamellar keratoplasty through a scleral incision, for management of corneal endothelial disorders like pseudophacic bullous keratopathy and Fuchs' endothelial dystrophy, and to report the mid-term clinical results.
Methods
Three techniques have been developed to perform a posterior lamellar keratoplasty procedure through a scleral incision, i.e. to replace the posterior corneal layers while leaving the anterior corneal surface intact and without the use of corneal sutures. In the first technique, a 9.0 mm scleral incision is made to accommodate an intracorneal trephine and spoon-shaped glide to insert a 7.5 mm donor posterior lamellar disc into the anterior chamber. In the second technique, the procedure is performed through a 5.0 mm scleral tunnel incision using microscissors and by folding a 8.5 mm donor posterior disc prior to insertion. In the third technique, a 4.0 mm tunnel incision is made to perform a descemetorhexis in the host cornea, i.e. Descemet's membrane is selectively excised from the recipient eye, and a 9.0 mm donor Descemet's membrane is inserted. In eyes with a minimal postoperative follow-up of 3–5 years (n=16), we documented the best spectacle corrected visual acuity (BSCVA), keratometry readings, endothelial cell counts, and clinical events.
Results
In all cases, the graft adhered to the recipient posterior cornea without suture fixation. In patients without concomitant ocular disease, BSCVA was 0.7–1.0 in all eyes. The astigmatism averaged 2.1±0.7 D, endothelial cell counts averaged 2126±529 cells/mm2 at 6 months, 1839±473 cells/mm2 at 12 months, 1418±434 cells/mm2 at 24 months, and 1137±420 cells/mm2 at 36 months. In two patients, an irido-corneal adhesiolysis was performed within days after the procedure. In one patient, residual visco-elastic adherence was present at the donor-to-recipient interface, and a penetrating keratoplasty was performed 1 month postoperation. One patient developed significant interface haze, requiring a penetrating keratoplasty 13 months after the first surgery.
Conclusion
Posterior lamellar keratoplasty can be an effective surgical technique to manage corneal endothelial disorders. An improved visual acuity can be obtained within the first weeks after surgery, and the visual perfomance of the graft is stable up to 5 years postoperation.
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Danksagungen
Unser herzlicher Dank gilt Herrn Bart T.H. van Dooren, M.D., und der Dutch Ophthalmic Research company (D.O.R.C.) für die gute Zusammenarbeit und Unterstützung.
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Melles, G.R.J., Kamminga, N. Techniken der posterioren lamellären Keratoplastik über einen skleralen Zugang. Ophthalmologe 100, 689–695 (2003). https://doi.org/10.1007/s00347-003-0891-2
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DOI: https://doi.org/10.1007/s00347-003-0891-2