5/13/2009

Lamellar Keratoplasty
Irving M. Raber Raber, , MD Attending Surgeon Cornea Service, Wills Eye Institute, Clinical Assistant Professor of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa.

Lamellar Keratoplasty
Anterior

ALTK DALK
Posterior

DSEK DMEK

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Deep Anterior Lamellar Keratoplasty (DALK)

Indications for DALK

Corneal

opacification with healthy endothelium Keratoconus Stromal dystrophies Corneal scarring

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Advantages of DALK vs PK
Less

rejection
d donor pool l

Avoids

intraocular penetration / positive pressure

Expands E d

Advantages of DALK vs PK
?

Earlier suture removal / visual rehabilitation ? Less endothelial cell loss ? Less cataract formation ? Less corneal weakening

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Disadvantages of DALK vs PK
Technically difficult technique Easy to convert to PK Longer duration of surgery ? Reduced quality of vision / best corrected visual acuity Interface can serve as a plane for vascularization / inflammation

DALK
Baring g

of Descemets membrane

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DALK TECHNIQUE
Big g

bubble b bb

Visco Visco-dissection Melles

stromal dissection over air bubble in anterior chamber Femtosecond laser assisted Intrastromal saline injection

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Descemets Stripping Endothelial Keratoplasty

(DSEK)

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Indications for DSEK

Endothelial

dysfunction/corneal

edema Absence of visually significant stromal scarring

Advantages of DSEK over PK

Quicker visual rehabilitation Less corneal weakening Minimal change in corneal power (IOL calculations, existing IOL) Minimal induced astigmatism Surgery done through small incision rather than open sky through trephine opening

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Contraindications for DSEK

Visually

significant corneal stromal

scarring Visually significant irregular astigmatism noted prior to onset of corneal edema i i.e. e in existing PK Silicone oil in AC

Relative Contraindications for DSEK

Monochamber o oc a be

g globe obe Anterior segment disorganization Anterior chamber IOL Clear Cl crystalline lli l lens

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Relative Contraindications for DSEK

Tube b

s shunt/s /s Filtering bleb Subepithelial scarring

If at all possible, I favor DSEK o over er PK PK. I can always revert to PK if DSEK fails although if the patient is willing I prefer to repeat DSEK.

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DSEK Technique
Donor

insertion

Folding forceps Busin Glide NCI injector PullPull -through suture +/+/ - infusion

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DSEK in Presence of Glaucoma Surgery

Tube

shunt /filtering bleb

Leave AC filled with air no need to release any air before discharge Occlude tube lumen or fistula site with a small amount of cohesive viscoelastic

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Management of Cataract with DSEK

Combined

Phacoemulsification (Ph ) and (Phaco) d insertion i i Posterior P i Chamber (PC) IOL Phaco/PC IOL prior to DSEK better IOL/Capsule bag stability

Management of Cataract with DSEK

If

suboptimal visualization through cornea can postpone cataract surgery until after cornea clears following DSEK. Other options include PK and combined Open Sky cataract/IOL surgery

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Management of Cataract with DSEK

Adjust j

PC IOL power p when aiming for Plano outcome use implant power calculated for -1.00 to -1.50 D outcome ?? Remove clear crystalline lens

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