Lamellar Keratoplasty• Manifest SE −10.38 D preoperatively, to −8.82 D at 3 months, and −9.25 D at 6 months postoperatively • Manifest refractive cylinder 3.5 D preoperatively,

$Page 1: Lamellar Keratoplasty• Manifest SE −10.38 D preoperatively, to −8.82 D at 3 months, and −9.25 D at 6 months postoperatively • Manifest refractive cylinder 3.5 D preoperatively,$
HSOIIRSHSOIIRS www.perfectvision.grwww.perfectvision.gr

MiltosMiltos BalidisBalidis PhD, FEBODPhD, FEBODPeriklisPeriklis MarkousisMarkousis MScMSc

Lamellar Lamellar KeratoplastyKeratoplasty


Deep Anterior Lamelar Deep Anterior Lamelar KeratoplastyKeratoplasty DALKDALK

•• Von Walther, Muhlbauer 1840Von Walther, Muhlbauer 1840•• Von Hippel, Filatov, Fuchs Von Hippel, Filatov, Fuchs •• Hallerman 1959 (Full Thickness Donor)Hallerman 1959 (Full Thickness Donor)•• Anwar 1972 (DM stripping)Anwar 1972 (DM stripping)•• Archilla 1997 (intrastromal air)Archilla 1997 (intrastromal air)•• Melles 1999 (AC air interface)Melles 1999 (AC air interface)•• Anwar 2002 (Big bubble)Anwar 2002 (Big bubble)


160160μμm SALKm SALK

160160--400400μμm 30m 30--75% MALK75% MALK

400400--495 495 μμm 90%DALKm 90%DALK

ClassificationClassification


TechniquesTechniques

•• Direct dissectionDirect dissection•• ΜΜelleselles technique (optical technique (optical

dissectiondissection))•• Ferrara technique (cyclic Ferrara technique (cyclic

dissectiondissection))•• ΑΑrchillarchilla technique (dissection technique (dissection

with airwith air))•• Anwar technique (dissection Anwar technique (dissection

with pre with pre descemetsdescemets air air bubblebubble))

•• FemtoFemto assisted assisted DalkDalk–– IntrabubbleIntrabubble

MellesMelles GRJ,etGRJ,et al.Aal.A new surgical technique for deep new surgical technique for deep stromal,anteriorstromal,anterior lamellar lamellar keratoplasty.Brkeratoplasty.Br J J Ophthalmol.1999;83(3):327Ophthalmol.1999;83(3):327--333.333.Anwar M, et al. BigAnwar M, et al. Big--bubble technique to bare bubble technique to bare Descemet’sDescemet’s membrane in anterior lamellar membrane in anterior lamellar keratoplasty.Jkeratoplasty.J Cataract Refract Surg.2002;28(12):398Cataract Refract Surg.2002;28(12):398--403.403.Lim Lim P,BradleyP,Bradley JC,etJC,et al.Histopathologyal.Histopathology of deep anterior lamellar of deep anterior lamellar keratoplastykeratoplasty with pneumatic with pneumatic dissection:thedissection:the “big“big--bubble”technique.Cornea.2009;28(5):579bubble”technique.Cornea.2009;28(5):579--582.582.BuzzonettiBuzzonetti L et al bigL et al big--bubble technique in deep anterior lamellar bubble technique in deep anterior lamellar keratoplastykeratoplasty assistedassistedby by femtosecondfemtosecond laser.Jlaser.J Cataract Refract Surg.2010;36(10):1631Cataract Refract Surg.2010;36(10):1631--1636.1636.


DALKDALK

Big BubbleBig Bubble

MellesMelles


••Optical visualization of dissection depth Optical visualization of dissection depth using Dr Melles techniqueusing Dr Melles technique“a“an airn air--toto--endothelium optical interface can endothelium optical interface can be used to visualize the corneal thickness be used to visualize the corneal thickness and the relative depth of a dissection knife and the relative depth of a dissection knife within the stroma during surgery, and with within the stroma during surgery, and with the optical effects described dissections the optical effects described dissections can be made to approximately the desired can be made to approximately the desired corneal depthcorneal depth””. . www.niioc.nl/edalkcrswww.niioc.nl/edalkcrs


MellesMelles


Pellucid Marginal DegenerationPellucid Marginal Degeneration

••Yellow arrow.Yellow arrow.••Optical reflection Optical reflection (right)(right)

••Descemet’s folds Descemet’s folds (middle))(middle))

••Red arrows : Red arrows : semisemi--circular, specular circular, specular lightlight--reflex reflex at the at the airair--toto--endothelium endothelium interface near the tip of the blade, interface near the tip of the blade, caused caused by the indentation of the by the indentation of the tissuetissue (left)(left)

VideosVideos



Femto MALKFemto MALK

FemtoFemto MALKMALK


FemtoFemto IntrabubbleIntrabubble

•• A channel in the posterior A channel in the posterior stromastroma of the recipient is of the recipient is created, 50 created, 50 μmμm above the above the endothelium and a smooth endothelium and a smooth cannulacannula is introduced into is introduced into this channel for air injection. this channel for air injection.

•• Descemet’sDescemet’s membrane membrane was consistently was consistently reached in all eyes (20 reached in all eyes (20 patients) treated with patients) treated with this version of the this version of the IntraBubbleIntraBubble techniquetechnique


Close to Close to Descemet’sDescemet’smembranemembrane

•• Air dissection clearly Air dissection clearly occurs above the level of occurs above the level of Descemet’sDescemet’s membrane.membrane.

•• Reaching the level of Reaching the level of Descemet’sDescemet’s membrane membrane minimizes the healing minimizes the healing process and thus the process and thus the production of haze, production of haze, thereby providing good thereby providing good corneal claritycorneal clarity

•• Lim Lim P,Bradley,etP,Bradley,et al.Histopathologyal.Histopathology of deep anterior lamellar of deep anterior lamellar keratoplastykeratoplasty with pneumatic with pneumatic dissection:The“bigbubble”technique.Cornea.2009;28(5):579dissection:The“bigbubble”technique.Cornea.2009;28(5):579--582.582.

•• AbdelkaderAbdelkader et al. et al. ConfocalConfocal microscopy of corneal wound healing after microscopy of corneal wound healing after deep lamellar deep lamellar keratoplastykeratoplasty in rabbits.ArchOphthalmol.2010;128(1):75in rabbits.ArchOphthalmol.2010;128(1):75--8080....



BCVABCVA

DALKDALK PKPPKP

KrumeichKrumeich 0.50.5 0.30.3 automatedautomated

TanTan 0.650.65 0.50.5 BBBBLarkin DLarkin D SIMSIM ILARILAR <20mmRSB<20mmRSBLarkin DLarkin D P>.0009P>.0009 >80mmRSB>80mmRSBFontanaFontana 0.650.65 BBBB

ArneArne 0.520.52 BB BB -- ViscVisc

DLCTSDLCTS 0.320.32 0.240.24 BBBB

CoombsCoombs 0.650.65 BB+HydroBB+Hydro

VabresVabres 0.780.78 0.80.8 BBBB


Endothelial cell countEndothelial cell count

DALKDALK PKPPKP

KrumeichKrumeich 19.7%19.7% 50%50% 5years auto5years auto

Larkin DLarkin D

TanTan 21.3%21.3% 48%48% 5 years5 years

FontanaFontana 7.62%7.62% 2years BBt2years BBt

ArneArne 22.5%22.5% BBt, ViscBBt, Visc

NobleNoble 13.3 %13.3 % 19%19% 2years BBt2years BBt

DLCTSDLCTS 23.7%23.7% 27%27% BBBB


Contrast SensetivityContrast Sensetivity

DALKDALK PKPPKP


LarkinLarkin


KeratometryKeratometry

DALKDALK PKPPKP

KrumeichKrumeich automatedautomatedFontanaFontana 15D dif15D dif Big BubbleBig BubbleArneArne 3.2 D dif3.2 D dif

CoombsCoombs 8.2 D8.2 D BB+HydroBB+HydroDLCTSDLCTS 3.283.28 4.54.5 BBBB


AstigmatismAstigmatism

DALKDALK PKPPKP


Larkin DLarkin D <20mmRSB<20mmRSBTanTan 2.72.7 3.53.5 BBBBFontanaFontana Big BubbleBig Bubble

DLCTSDLCTS 3.383.38 4.14.1 BBBB

CoombsCoombs 3.853.85 BB+HydroBB+Hydro

NobleNoble MellesMelles

VabresVabres 3 D3 D 3.5 D3.5 D BB vs PKPBB vs PKP


1.1. Quality of vision and graft thickness in deep anterior lamellar and Quality of vision and graft thickness in deep anterior lamellar and penetrating corneal allograftspenetrating corneal allografts Larkin DF et alLarkin DF et al Am J Ophthalmol. 2007 Am J Ophthalmol. 2007 Feb;143(2):228Feb;143(2):228--235.235.

2.2. Deep anterior lamellar (DALK) vs. penetrating keratoplasty (PKP): Deep anterior lamellar (DALK) vs. penetrating keratoplasty (PKP): Krumeich JHKrumeich JH et al et al Klin Monatsbl Augenheilkd. 2008 Jul;225(7):637Klin Monatsbl Augenheilkd. 2008 Jul;225(7):637--48. 48.

3.3. Clinical outcomes after deep anterior lamellar keratoplasty using the bigClinical outcomes after deep anterior lamellar keratoplasty using the big--bubble.Fontana L Am J Ophthalmol. 2007 Jan;143(1):117bubble.Fontana L Am J Ophthalmol. 2007 Jan;143(1):117--124. Epub 124. Epub 2006 Oct 20.2006 Oct 20.

4.4. Deep anterior lamellar keratoplasty in the surgical treatment of Deep anterior lamellar keratoplasty in the surgical treatment of keratoconus Arné JL. J Fr Ophtalmol. 2006 Jun;29(6):602keratoconus Arné JL. J Fr Ophtalmol. 2006 Jun;29(6):602--13. 13.

5.5. Deep Anterior Lamellar Keratoplasty (DALK): visual outcome and Deep Anterior Lamellar Keratoplasty (DALK): visual outcome and complications.Noble BA, et al Cornea. 2007 Jan;26(1):59complications.Noble BA, et al Cornea. 2007 Jan;26(1):59--64. 64.

6.6. J Fr Ophtalmol. 2006 Apr;29(4):361J Fr Ophtalmol. 2006 Apr;29(4):361--71.Deep lamellar keratoplasty 71.Deep lamellar keratoplasty versus penetrating keratoplasty for keratoconus Vabres B et alversus penetrating keratoplasty for keratoconus Vabres B et al

7.7. Tan DT, Ang LP. Modified automated lamellar therapeutic keratoplasty Tan DT, Ang LP. Modified automated lamellar therapeutic keratoplasty for keratoconus: a new technique. Cornea 2006;25(10):1217for keratoconus: a new technique. Cornea 2006;25(10):1217--1219.1219.

8.8. Shimazaki J, Shimmura S, Ishioka M, et al. Randomized clinical trial of Shimazaki J, Shimmura S, Ishioka M, et al. Randomized clinical trial of deep lamellar keratoplasty vs penetrating keratoplasty. Am J deep lamellar keratoplasty vs penetrating keratoplasty. Am J Ophthalmol. 2002;134:159Ophthalmol. 2002;134:159––165165


PK v DALK , TanPK v DALK , Tan

•• Μ.Τ.Μ.Τ.EEνδοθηλιακώννδοθηλιακών–– 1ετος 28951ετος 2895 26292629–– 3ετη 18483ετη 1848 22742274–– 4ετη 16564ετη 1656 21432143–– 5ετη 15035ετη 1503 2068 2068

•• AAπώλεια πώλεια ενδοθηλιακών ενδοθηλιακών κυττάρωνκυττάρων–– 38.1%38.1%–– 7.7% (7.7% (p .0042)p .0042)





•• ‘We can only call penetrating‘We can only call penetratingkeratoplasty a temporary keratoplasty a temporary procedure.procedure.

•• After five years 25 per cent After five years 25 per cent will havewill have to be reto be re--operated. operated. Based on our data,Based on our data, DALK DALK should be used, whenever should be used, whenever thethe endothelium is normal, to endothelium is normal, to finally heal thefinally heal the corneal corneal disease’disease’

•• KrumeichKrumeich



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HeterograftsHeterografts 19631963

Agarwal LP, et al Intralamellar Heterografts Agarwal LP, et al Intralamellar Heterografts of frog cornea of frog cornea Br J Ophthalmol. 1963 Jan;47:14Br J Ophthalmol. 1963 Jan;47:14--3030


IntralamelarIntralamelarkeratoplastykeratoplasty

•• LLamellaramellar interfaceinterface atat a a depthdepth ofof 400 400 μmμm posteriorposterior toto thethe epithelialepithelial surfacesurface. . •• TheThe diameterdiameter ofof thethe lamellarlamellar cutcut waswas 9 mm. 9 mm. •• A A sideside cutcut waswas thenthen performedperformed creatingcreating a a taperedtapered edgeedge toto thethe lenticulelenticule. . •• AA secondsecond superficialsuperficial lamellarlamellar cutcut waswas mademade atat a a depthdepth ofof 150 150 μmμm

posteriorposterior toto thethe epithelialepithelial surfacesurface•• DavidDavid J. J. SchanzlinSchanzlin et al et al NEW SURGICAL APPROACHES TO THE MANAGEMENT OF NEW SURGICAL APPROACHES TO THE MANAGEMENT OF

KERATOCONUS AND POSTKERATOCONUS AND POST--LASIK ECTASIA LASIK ECTASIA TransTrans AmAm OphthalmolOphthalmol SocSoc. 2006 . 2006 DecemberDecember; 104: ; 104: 212212––220220

150μm

250μm

150μm


IntralamelarIntralamelarkeratoplastykeratoplasty

•• BCVA 0.88 BCVA 0.88 ±± 0.34 (20/150) preop to 0.40 0.34 (20/150) preop to 0.40 ±± 0.09 (20/50) at 3 months and to 0.48 0.09 (20/50) at 3 months and to 0.48 ±±0.06 (20/60) at 6 months postop.0.06 (20/60) at 6 months postop.

•• All eyes gained between 1 and 8 lines of BCVA at 6 months .All eyes gained between 1 and 8 lines of BCVA at 6 months .•• MManifest SE −10.38 D preoperatively, to −8.82 D at 3 months, and −9.25 D at 6 anifest SE −10.38 D preoperatively, to −8.82 D at 3 months, and −9.25 D at 6

months postoperatively months postoperatively •• MManifest refractive cylinder 3.5 D preoperatively, to 2.25 D at 3 months, and 1.68 D at anifest refractive cylinder 3.5 D preoperatively, to 2.25 D at 3 months, and 1.68 D at

6 months postoperatively (a reduction by 1.82 D, 6 months postoperatively 6 months postoperatively (a reduction by 1.82 D, 6 months postoperatively

Intralamellar keratoplasty group. BCVA pre) and post 6 months

Intrastromal corneal ring segments group. BCVA pre and post 6 months


TissueTissue--EngineeredEngineeredRecombinantRecombinant HumanHuman

CollagenCollagen ΙΙ, ΙΙΙ, ΙΙΙ

•• RHCRHC--I and I and --III implants can be safely and stably III implants can be safely and stably integrated into host corneas. integrated into host corneas.

•• Optical clarity was maintained in both implants Optical clarity was maintained in both implants RHCRHC--III implants showed superior optical clarityIII implants showed superior optical clarity

–– Kimberley Merrett, Per Fagerholm TissueKimberley Merrett, Per Fagerholm Tissue--Engineered Engineered Recombinant Human CollagenRecombinant Human Collagen--Based Corneal Based Corneal Substitutes for Implantation: Performance of Type I Substitutes for Implantation: Performance of Type I versus Type III Collagenversus Type III Collagen IOVS. 2008;49:3887IOVS. 2008;49:3887--38943894


•• Over Over 12 months show comparably stable 12 months show comparably stable integration, with regeneration of corneal cells, integration, with regeneration of corneal cells, tear film, and nerves.tear film, and nerves.

TissueTissue--EngineeredEngineered RecombinantRecombinantHumanHuman CollagenCollagen Ι, ΙΙΙΙ, ΙΙΙ


•• ‘Nerve regeneration in recombinant human ‘Nerve regeneration in recombinant human collagencollagen--based biosynthetic corneal grafts based biosynthetic corneal grafts proceeded similarly to that in allograft tissue, proceeded similarly to that in allograft tissue, demonstrating the suitability of recombinant demonstrating the suitability of recombinant human collagen constructs as nervehuman collagen constructs as nerve--friendly friendly corneal substitutes. Furthermore, only minor corneal substitutes. Furthermore, only minor differences were noted between typedifferences were noted between type--I and I and --III III collagen grafts, indicating an insensitivity of collagen grafts, indicating an insensitivity of nerve regeneration to initial collagen type’.nerve regeneration to initial collagen type’.

»» Griffith M, Fagerholm P Griffith M, Fagerholm P et alet al Invest Ophthalmol Vis Sci. Invest Ophthalmol Vis Sci. 2008 Sep;49(9):38952008 Sep;49(9):3895--902. 902.

TissueTissue--EngineeredEngineered RecombinantRecombinantHumanHuman CollagenCollagen Ι, ΙΙΙΙ, ΙΙΙ



Documents

Lamellar Keratoplasty• Manifest SE −10.38 D preoperatively, to −8.82 D at 3 months, and −9.25 D at 6 months postoperatively • Manifest refractive cylinder 3.5 D preoperatively,