Therapeutic deep lamellar keratoplasty for cornea perforation

doi:10.1016/S0002-9394(02)02172-4

American Journal of Ophthalmology

Volume 135, Issue 6, June 2003, Pages 896-897

https://doi.org/10.1016/S0002-9394(02)02172-4 Get rights and content

Abstract

Purpose

To present the efficacy of performing deep lamellar keratoplasty as an emergency measure following perforation of the cornea.

Design

Interventional case report.

Methods

Deep lamellar keratoplasty was performed in two cases of perforated cornea. Following incarceration of the iris within the perforated area, The Descemet membrane was exposed except for strands of stroma surrounding the perforation. A fresh donor cornea stripped of the Descemet membrane was then sutured in place.

Results

Both cases have attained clear corneas in areas other than the original perforation.

Conclusions

Deep lamellar keratoplasty is a safe technique for the treatment of cornea perforation.

References (5)

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Multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera
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J.M. Richard et al.
A comparison of penetrating keratoplasty and lamellar keratoplasty in the surgical management of keratoconus
Am J Ophthalmol
(1978)

There are more references available in the full text version of this article.

Cited by (39)

Management of Corneal Perforation
2011, Survey of Ophthalmology
Citation Excerpt :
Because fibrin sealant is a biological, it resorbs completely in a few days. Deep lamellar keratoplasty has been successfully performed with corneal melting secondary to gonococcal ocular infection.12,141,159 In these cases a gentle exposure of deep corneal stroma is achieved using a hydrodissection approach rather than using the big bubble technique.
Corneal perforation may be associated with prolapse of ocular tissue and requires prompt diagnosis and treatment. Although infectious keratitis is an important cause, corneal xerosis and collagen vascular diseases should be considered in the differential diagnosis, especially in cases that do not respond to conventional medical therapy. Although medical therapy is a useful adjunct, a surgical approach is required for most corneal perforations. Depending on the size and location of the corneal perforation, treatment options include gluing, amniotic membrane transplantation, and corneal transplantation.
Deep anterior lamellar keratoplasty using acellular corneal tissue for prevention of allograft rejection in high-risk corneas
2011, American Journal of Ophthalmology
Citation Excerpt :
Therapeutic PK is normally reserved in high-risk corneas because of increased graft failure and allograft rejection rates, and the reported rates of graft rejection after therapeutic PK fluctuated dramatically in various series.3,12,21–26 As a surgical innovation in lamellar corneal transplantation, DALK is a recent treatment for high-risk corneas that has been reported to benefit selected cases of fungal, bacterial, and acanthamoeba keratitis.1–3,27–29 The DALK procedure offers other unique advantages for high-risk corneas.
To determine whether deep anterior lamellar keratoplasty (DALK) using acellular glycerol-cryopreserved corneal tissue (GCCT) could prevent allograft rejection in high-risk corneas.
Prospective, randomized, comparative study.
settings: The Eye Hospital, Wenzhou Medical College, Zhejiang, China. study population: All patients with herpes simplex virus keratitis, bacterial keratitis, fungal keratitis, or ocular burn, who were eligible as per study design, were invited to participate. observation procedures: According to randomized block design, all patients received either GCCT or fresh corneal tissue (FCT) during DALK. Best-corrected visual acuity (BCVA), slit-lamp microscopy, and in vivo confocal microscopy examinations at 1 week and 1, 3, 6, 12, and 24 months after surgery were analyzed. Kaplan-Meier survival analysis was used to evaluate graft survival rate. main outcome measures: Therapeutic success, 2-year rejection-free graft survival rate and 2-year graft survival rate, in vivo confocal microscopy results, BCVA, and endothelial cell density.
Postoperative BCVA of 20/40 or better at the last follow-up visit was achieved in 57.6% (19/33) of eyes in the GCCT group and in 54.8% (17/31) of the FCT group. No graft rejection occurred in the GCCT group, while in the FCT group 10 episodes of stromal rejection developed in 7 eyes. Overall, the rejection-free graft survival rate at 2 years was significantly higher in the GCCT group as compared with the FCT group (100.0%, 78.8% respectively, P = .006).
Deep anterior lamellar keratoplasty using acellular glycerol-preserved cornea could prevent allograft rejection and promote graft survival rate in high-risk corneas.
Evolution of deep anterior lamellar keratoplasty (DALK)
2011, Ocular Surface
Citation Excerpt :
In cases of large macroperforation, the surgery must be converted to PK. As a therapeutic treatment for infectious corneal diseases, DALK has some advantages over PK,104,109,114,145 eventhough the possibility of infection recurrence exists. In a retrospective case-comparison study examining the role of therapeutic DALK versus therapeutic PK in advanced infectious keratitis, recurrence of infection occurred in 15.3% of DALK patients, similar to the 12% in the PK patients.22
The concept of selective tissue transplantation was theorized over two centuries ago. However, deep anterior lamellar keratoplasty (DALK) was difficult to perform with the instruments available at that time, and visual acuity results were poor compared to those achieved by full-thickness transplantation. Recently, many technical improvements in surgical instrumentation and advances in eye bank technology have led to the re-emergence of DALK. Now, patients with stromal pathologies not affecting the corneal endothelium can benefit from this surgery, which allows total stromal replacement of the recipient's cornea, leaving an intact recipient Descemet membrane and endothelium. Along with the advances in surgical instrumentation, improvements in surgical techniques and imaging technology have contributed to improved visual outcomes obtained with DALK. DALK is now seen as a viable alternative to penetrating keratoplasty with equivalent visual results and better long-term graft survival.
Deep anterior lamellar Keratoplasty
2009, Saudi Journal of Ophthalmology
Keratoconus is a disease causing increased steepening of the cornea resulted in irregular astigmatism. Treatment options are Glasses, Hard contact lenses, Cross linking, Intracorneal Segments insertion, Refractive surgery (Gilda et al., 2008), or Keratoplasty. Lamellar Keratoplasty (LKP) can be a better choice to manage cases of moderate and some cases of severe Keratoconus without deep scarring and severe thinning, also in cases of corneal scarring not involving the deeper layers of the cornea. LKP is a corneal graft technique consisting of transplantation of partial-thickness donor tissue, devoid of endothelium, Descemet membrane (DM), and rear stroma into a recipient healthy stromal bed after dissection of pathologic anterior stroma. However, deep lamellar Keratoplasty (DLKP) is a surgical method that completely removes pathologic corneal stroma tissue down to the DM, followed by transplantation of donor cornea without endothelium over the host bed. DLKP has a number of advantages over penetrating Keratoplasty (PKP). Because it does not violate the intraocular structures of the eye, it diminishes or eliminates the chance of postoperative glaucoma, cataract formation, retinal detachment, cystoids macular edema, expulsive choroidal hemorrhage and epithelial ingrowths. Furthermore, this procedure avoids the replacement of host endothelium with donor endothelium and thus precludes endothelial graft rejection, with comparable visual outcomes and low rate of chronic endothelial cell loss compared to PKP.
Outcomes of Therapeutic Deep Lamellar Keratoplasty and Penetrating Keratoplasty for Advanced Infectious Keratitis. A Comparative Study
2009, Ophthalmology
Citation Excerpt :
Of particular note is our success with disease eradication in acanthamoeba keratitis; of the 9 eyes with acanthamoeba keratitis that underwent TDALK, 8 were successful in eradicating infection at the first attempt, (88.9% therapeutic success), and a repeat TDALK procedure in the remaining eye with disease recurrence was successful. We are unaware of previous reports describing therapeutic success rates after a lamellar procedure for acanthamoeba keratitis, while in contrast, it is well recognized that recurrence rates after PK for acanthamoeba have been reported to range from 40% to 50%.8–23 In the TPK cohort with recurrences, the final outcome was poor; 9 out of 12 eyes ultimately underwent evisceration.
To compare the therapeutic success, visual outcomes, complications, and graft survival rates of therapeutic deep anterior lamellar keratoplasty (TDALK) and therapeutic penetrating keratoplasty (TPK) for advanced infectious keratitis.
Retrospective, comparative study.
One hundred twenty-three patients (126 eyes) with medically uncontrolled infectious keratitis of bacterial, fungal, or acanthamoeba etiologies who underwent TDALK (n = 26) or TPK (n = 100 eyes; 80 nonperforated ulcers; 20 perforated ulcers; mean follow-up in TDALK, 12.9 months; in TPK, 21.3 months).
We performed TDALK for infections confined to the corneal stroma and the technique used was either manual lamellar dissection or Anwar's big bubble technique for total stromal removal. Therapeutic penetrating keratoplasty was performed for either nonperforated or perforated ulcers. Comparison with respect to recurrence of infection, visual acuity, graft survival, and complications was made. Baseline characteristics of the patients were analyzed using the chi-square test. Kaplan–Meier survival analysis was used to evaluate graft survival.
Therapeutic success (eradication of infection) or therapeutic failure (recurrence of original infection in cornea or sclera, or as endophthalmitis), graft survival (clarity), and best-corrected visual acuity (BCVA).
Therapeutic success rate of 84.6% was achieved in the TDALK group and 88% in the TPK group (P = 0.74); of the 12 eyes with recurrence of infection in the TPK cohort, 6 developed endophthalmitis with poor outcomes. A BCVA of ≥6/9 was achieved in 50% of patients in the TDALK group and 20.2% in the TPK group (P = 0.01). Mean improvement of acuity was 7.27 lines in the TDALK group and 4.76 lines in the TPK group (P = 0.01). Kaplan–Meier survival analysis at 1 year showed better graft survival for TDALK (90%) compared with TPK (78.4%).
For medically unresponsive infectious keratitis, TDALK may be considered instead of TPK yielding similar graft survival, without an increased risk of disease recurrence.
The authors have no proprietary or commercial interest in any materials discussed in this article.
Deep anterior lamellar keratoplasty
2008, Corneal Surgery: Theory Technique and Tissue: Fourth Edition

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Brief reportTherapeutic deep lamellar keratoplasty for cornea perforation

Abstract

Purpose

Design

Methods

Results

Conclusions

Ophthalmol

Am J Ophthalmol

Brief report
Therapeutic deep lamellar keratoplasty for cornea perforation