Never conver pushing the limits of the DALK techniques data presented at the VII World Cornea...

32 INTERNATIONAL CONGRESS of the

HELLENIC SOCIETY OF INTRAOCULAR IMPLANT

AND REFRACTIVE SURGERY

ATHENS DALK COURSE – BEST OF AAO

Never conver – pushing the limits

of the DALK techniques

Vincenzo Sarnicola, MD

Clinica Degli Occhi Sarnicola, Grosseto

No financial interest to disclose.

DM ruptures rate: 4-39%*

*Tan DT, Dart JK, Holland EJ, Kinoshita S. Corneal transpantation. Lancet 2012;379:1749-61

PK conversion rate: 0-60%**

**-Reinhart WJ et al. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by

the american academy of ophthalmology. Opthalmology 2011;118:209-18

Sarnicola V, Sarnicola E, Sarnicola C. DALK: all the ruptures can be fixed. Unpublish data presented at the

VII World Cornea Congress, San Diego, 2015

- D. Smadja, J. Colin, R.R. Krueger, et al. Outcomes of deep anterior lamellar keratoplasty for keratoconus:

learning curve and advantages of the big bubble Technique. Cornea. 2012;31:859-863.-

LITERATURE

(Surgeon’s expertise)

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

*Kubaloglu A, Sari ES, Unal M, et al. Long-term results of deep anterior lamellar keratoplasty for the treatment of keratoconus.

Am J Ophthalmol 2011;151:760-767.

LITERATURE Clinica degli occhi Sarnicola

Vincenzo Sarnicola

METHODS:

-Retrospective study

- 1084 DALK in 908 patients (2002-2013)

- DM ruptures

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

TYPE of RUPTURES

- 91/1084 DM ruptures (8,4%)

• 62 in dDALK 62/889 = 7%

• 29 in pdDALK 29/195 = 15%

1084 DALK (2002-2013)• 889 dDALK (82%)

• 195 pdDALK (18%)

- 19/ 91 MACRO (>2mm) ruptures (21%)

• 15 in dDALK 15/62 = 24%

• 4 in pdDALK 4/29 = 14%

- 72/91 MICRO ruptures (79%)

• 47 in dDALK 47/62= 76%

• 25 in pdDALK 25/29 = 86%

100%

100%

dDALK pdDALK

Clinica degli occhi Sarnicola

91/1084 DM ruptures (8,4%)

Vincenzo Sarnicola

SITE of RUPTURES

- 91/1084 DM ruptures (8,4%)

• 62 in dDALK 62/889 = 7%

• 29 in pdDALK 29/195 = 15%

- CENTRAL-PARACENTRAL: 4/91 = 4,4%

• 0 dDALK

• 4 pdDALK 100%

- PERIPHERAL: 87/91 = 95,6%

• 62 dDALK

• 25 pdDALK

- 39 lateral (temporal or nasal)

- 32 superior

- 16 inferior

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

… there is no reasons for replacing an healthy

endothelium… EVER!!!

V. Sarnicola, ESCRS, 2009

Vincenzo Sarnicola

Clinica degli occhi Sarnicola

RUPTURES MANAGEMENTClinica degli occhi Sarnicola

Vincenzo Sarnicola

RUPTURES MANAGEMENT

Clinica degli occhi Sarnicola

1.- Complete the stromectomy !

2.- Don’t inject air into the A.C. !

3.- Suture the donor first !

4.- Then…inject air into the A.C. !!!

5.- Move the eye in order to remove

interface fluids !

6.- Patient’s head positioning.

HEAD POSITIONING

LATERAL RUPTURE SUPERIOR RUPTURE

INFERIOR RUPTURE

Clinica degli occhi Sarnicola

EXCESSIVE TREPHINATION

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Suggestions:

1.- Suture the zone of

perforation

2.- Layer by layer delamination

3.- Suture the donor

4.- Delaminate the zone of

perforation

5.- Then put Air into the A.C.

6.- Move the eye in order to

remove interface fluids

EXCESSIVE TREPHINATION

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

RUPTURES OUTCOMES:

- 75 ruptures (82,4%) resulted repaired at 1st day post-op.1 case was due to excessive corneal trephination

- 16 cases (17,6%) developed

No PK conversion was recorded !!

10 cases fixed with single rebubbling (head position)

3 cases with 2 rebubbling and suture replacement.

3 cases, with recipient bed (RB) cut due to

donor-recipient disparity of curvature

- 91 DM ruptures were recorded. (91/1084 = 8,4%)

double anterior chamber

Clinica degli occhi Sarnicola

Disparity: mismatch between donor

and recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Disparity: mismatch between donor

and recipient curvature

1. Recipient is steeper than donor

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

1. Recipient is steeper than donor

Disparity: mismatch between donor and

recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

1. Recipient is steeper than donor

2. Recipient is flatter than donor

Disparity: mismatch between donor and

recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

1. Recipient is steeper than donor

2. Recipient is flatter than donor

Disparity: mismatch between donor and

recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

1. Recipient is steeper than donor

2. Recipient is flatter than donor

Disparity: mismatch between donor and

recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipientClinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient

45 D

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

45 D

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

60 D

KERATOGLOBUS

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

pdDALK in KERATOGLOBUS

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

20 DAYS POSTOPClinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

Steeper recipient

Rupture

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

Steeper recipient

Rupture

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

EXTREME KERATOGLOBUSClinica degli occhi Sarnicola

Vincenzo Sarnicola

pdDALK in KERATOGLOBUSClinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient

Rupture

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

FULL TICKNESS

TOTAL CIRCULAR CUT

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Full thickness

total circular cut

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

DALK

allograft

Full thickness

total circular cut

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

DALK

allograft

Self endothelium

Full thickness

total circular cut

FULL TICKNESS TOTAL CIRCULAR CUT

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

1ST DAY POST-OPClinica degli occhi Sarnicola

Vincenzo Sarnicola

40 DAYS POST-OPClinica degli occhi Sarnicola

Vincenzo Sarnicola

40 DAYS POST-OPClinica degli occhi Sarnicola

Vincenzo Sarnicola

PREOP POSTOP

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

1. Recipient is steeper than donor

2. Recipient is flatter than donor

Disparity: mismatch between donor and

recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Flatter recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

MASSIVE DESTRUCTION OF THE STROMA

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Vincenzo Sarnicola, ASCRS, Boston 2014

5 MONTHS THERAPY(ORAL ACYCLOVIR, LOTEPREDNOL EYE DROPS)

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Vincenzo Sarnicola, ASCRS, Boston 2014

SURGERY IN MASSIVE DESTRUCTION OF THE STROMA

Rules:

DALK…and only DALK

Large stromectomy

Layer by layer delamination

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Vincenzo Sarnicola, ASCRS, Boston 2014

pdDALK in MASSIVE DESTRUCTION OF THE STROMA

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Vincenzo Sarnicola, ASCRS, Boston 2014

DOUBLE CHAMBERDONOR-HOST DISPARITY OF CURVATURE

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Day 9 post-op

FLATTER

STEEPER

Flatter recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Flatter recipient

MANAGEMENT

SUBTOTAL

CIRCULAR

RECIPIENT’S

BED CUT

Saved DM at 6 o’clock

Vincenzo Sarnicola, ASCRS, Boston 2014

SUBTOTAL CIRCULAR RECIPIENT’S BED CUT

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Day 60 postop

Clinica degli occhi Sarnicola

One year post-op

Clinica degli occhi Sarnicola

Preop

One year post-op

can help you reducing “PK conversion rate”…

TAKE HOME MESSAGE

… if you get a rupture in pd-DALK

… NEVER forget to care about the DISPARITY

of curvature

… Full Thickness Circular Cut

STEEPER RECIPIENT FLATTER RECIPIENT

SUB-TOTALTOTAL

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

WET LABS

LIVE PATIENTS

EVALUATION

INTERACTIVE

CLINICAL

CASES

SICSSO 2014

in PAESTUM

WET LABsS.I.C.S.S.O.

PARTY !!!