Never conver pushing the limits of the DALK techniques data presented at the VII World Cornea Congress, San Diego, 2015 - D. Smadja, J. Colin, R.R. Krueger, et al. Outcomes of deep

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


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


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


Vincenzo Sarnicola

… there is no reasons for replacing an healthy

endothelium… EVER!!!

V. Sarnicola, ESCRS, 2009

Vincenzo Sarnicola


RUPTURES MANAGEMENTClinica degli occhi Sarnicola

Vincenzo Sarnicola

RUPTURES MANAGEMENT


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


EXCESSIVE TREPHINATION


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


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


Disparity: mismatch between donor

and recipient curvature


Vincenzo Sarnicola

Disparity: mismatch between donor

and recipient curvature

1. Recipient is steeper than donor


Vincenzo Sarnicola


Disparity: mismatch between donor and

recipient curvature


Vincenzo Sarnicola


2. Recipient is flatter than donor


recipient curvature


Vincenzo Sarnicola




recipient curvature


Vincenzo Sarnicola




recipient curvature


Vincenzo Sarnicola

Steeper recipientClinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient

45 D


Vincenzo Sarnicola

45 D

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola


Vincenzo Sarnicola

60 D

KERATOGLOBUS



Vincenzo Sarnicola

pdDALK in KERATOGLOBUS



Vincenzo Sarnicola

20 DAYS POSTOPClinica degli occhi Sarnicola

Vincenzo Sarnicola


Vincenzo Sarnicola


Vincenzo Sarnicola


Vincenzo Sarnicola

Rupture

Steeper recipient

Rupture


Vincenzo Sarnicola

Rupture

Steeper recipient

Rupture


Vincenzo Sarnicola

Rupture

EXTREME KERATOGLOBUSClinica degli occhi Sarnicola

Vincenzo Sarnicola

pdDALK in KERATOGLOBUSClinica degli occhi Sarnicola

Vincenzo Sarnicola

Steeper recipient

Rupture


Vincenzo Sarnicola

Rupture

FULL TICKNESS

TOTAL CIRCULAR CUT


Vincenzo Sarnicola

Full thickness

total circular cut



Vincenzo Sarnicola


Vincenzo Sarnicola

DALK

allograft

Full thickness

total circular cut


Vincenzo Sarnicola

DALK

allograft

Self endothelium

Full thickness

total circular cut

FULL TICKNESS TOTAL CIRCULAR CUT



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




recipient curvature


Vincenzo Sarnicola

Flatter recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

MASSIVE DESTRUCTION OF THE STROMA


Vincenzo Sarnicola


5 MONTHS THERAPY(ORAL ACYCLOVIR, LOTEPREDNOL EYE DROPS)


Vincenzo Sarnicola


SURGERY IN MASSIVE DESTRUCTION OF THE STROMA

Rules:

DALK…and only DALK

Large stromectomy

Layer by layer delamination


Vincenzo Sarnicola


pdDALK in MASSIVE DESTRUCTION OF THE STROMA


Vincenzo Sarnicola


DOUBLE CHAMBERDONOR-HOST DISPARITY OF CURVATURE


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


SUBTOTAL CIRCULAR RECIPIENT’S BED CUT


Vincenzo Sarnicola

Day 60 postop


One year post-op


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


Vincenzo Sarnicola

WET LABS

LIVE PATIENTS

EVALUATION

INTERACTIVE

CLINICAL

CASES

SICSSO 2014

in PAESTUM

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

PARTY !!!

Documents

Never conver pushing the limits of the DALK techniques data presented at the VII World Cornea Congress, San Diego, 2015 - D. Smadja, J. Colin, R.R. Krueger, et al. Outcomes of deep