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Page 1: 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.

Page 2: 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

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

Page 3: 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

*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

Page 4: 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

METHODS:

-Retrospective study

- 1084 DALK in 908 patients (2002-2013)

- DM ruptures

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 5: 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

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

Page 6: 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

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

Page 7: 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

… there is no reasons for replacing an healthy

endothelium… EVER!!!

V. Sarnicola, ESCRS, 2009

Vincenzo Sarnicola

Clinica degli occhi Sarnicola

Page 8: 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

RUPTURES MANAGEMENTClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 9: 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

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.

Page 10: 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

HEAD POSITIONING

LATERAL RUPTURE SUPERIOR RUPTURE

INFERIOR RUPTURE

Clinica degli occhi Sarnicola

Page 11: 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

EXCESSIVE TREPHINATION

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 12: 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

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

Page 13: 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

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

Page 14: 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

Disparity: mismatch between donor

and recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 15: 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

Disparity: mismatch between donor

and recipient curvature

1. Recipient is steeper than donor

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 16: 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

1. Recipient is steeper than donor

Disparity: mismatch between donor and

recipient curvature

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 17: 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

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

Page 18: 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

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

Page 19: 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

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

Page 20: 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

Steeper recipientClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 21: 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

Steeper recipient

45 D

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

45 D

Page 22: 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

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 23: 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

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

60 D

Page 24: 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

KERATOGLOBUS

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 25: 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

pdDALK in KERATOGLOBUS

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 26: 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

20 DAYS POSTOPClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 27: 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

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 28: 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

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 29: 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

Steeper recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

Page 30: 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

Steeper recipient

Rupture

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

Page 31: 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

Steeper recipient

Rupture

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

Page 32: 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

EXTREME KERATOGLOBUSClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 33: 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

pdDALK in KERATOGLOBUSClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 34: 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

Steeper recipient

Rupture

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Rupture

Page 35: 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

FULL TICKNESS

TOTAL CIRCULAR CUT

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 36: 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

Full thickness

total circular cut

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 37: 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

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

DALK

allograft

Full thickness

total circular cut

Page 38: 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

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

DALK

allograft

Self endothelium

Full thickness

total circular cut

Page 39: 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

FULL TICKNESS TOTAL CIRCULAR CUT

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 40: 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

1ST DAY POST-OPClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 41: 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

40 DAYS POST-OPClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 42: 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

40 DAYS POST-OPClinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 43: 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

PREOP POSTOP

Vincenzo Sarnicola, ASCRS, Boston 2014

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 44: 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

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

Page 45: 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

Flatter recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 46: 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

MASSIVE DESTRUCTION OF THE STROMA

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 47: 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

Vincenzo Sarnicola, ASCRS, Boston 2014

5 MONTHS THERAPY(ORAL ACYCLOVIR, LOTEPREDNOL EYE DROPS)

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 48: 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

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

Page 49: 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

Vincenzo Sarnicola, ASCRS, Boston 2014

pdDALK in MASSIVE DESTRUCTION OF THE STROMA

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 50: 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

Vincenzo Sarnicola, ASCRS, Boston 2014

DOUBLE CHAMBERDONOR-HOST DISPARITY OF CURVATURE

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Day 9 post-op

FLATTER

STEEPER

Page 51: 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

Flatter recipient Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 52: 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

Flatter recipient

Page 53: 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

MANAGEMENT

SUBTOTAL

CIRCULAR

RECIPIENT’S

BED CUT

Page 54: 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

Saved DM at 6 o’clock

Page 55: 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

Vincenzo Sarnicola, ASCRS, Boston 2014

SUBTOTAL CIRCULAR RECIPIENT’S BED CUT

Clinica degli occhi Sarnicola

Vincenzo Sarnicola

Page 56: 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

Day 60 postop

Clinica degli occhi Sarnicola

One year post-op

Page 57: 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

Clinica degli occhi Sarnicola

Preop

One year post-op

Page 58: 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

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

Page 59: 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

WET LABS

LIVE PATIENTS

EVALUATION

INTERACTIVE

CLINICAL

CASES

Page 60: 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

SICSSO 2014

in PAESTUM

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

PARTY !!!


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