Small-incision deep lamellar endothelial keratoplasty (DLEK): six-month results in the first prospective clinical study

PURPOSE: To evaluate the visual, topographic, and endothelial survival results in 25 consecutive patients who have received small-incision deep lamellar endothelial keratoplasty (DLEK) transplant surgery. METHODS: DLEK surgery was performed in 25 patients with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy utilizing a 5-mm scleral access incision. Snellen visual acuities, refractive astigmatism, endothelial cell counts, and corneal topography were prospectively measured at preop and at 6 months after small-incision DLEK endothelial replacement surgery. RESULTS: Best spectacle-corrected visual acuity improved from an average of 20/90 (range 20/25 to 2'/200) before surgery to an average of 20/44 (range 20/25 to 20/200, P < 0.001) 6 months after surgery, with 56% of patients 20/40 or better at 6 months. Average refractive astigmatism at 6 months was 1.31 +/- 0.59 diopters (range 0.25 to 2.50 diopters), representing an average increase in astigmatism of 0.45 diopters from preop. Despite folding of the donor graft for placement into the recipient posterior lamellar bed, the average postoperative endothelial cell count at 6 months was 2122 +/- 510 cells/mm2 (range 1097 to 3202 cells/mm2) or an average 24% cell loss from donor eye preop measurements, a level of cell loss comparable to that reported after PK or after large-incision DLEK surgery. CONCLUSION: Small-incision DLEK surgery preserves the recipient corneal topography, resulting in very little change in astigmatism from preop. The excellent postoperative donor endothelial cell counts attest to the survival of donor endothelium despite folding of the graft for insertion. The small-incision DLEK technique may become the standard for endothelial replacement surgery in the future.     

Replacing the endothelium without corneal surface incisions or sutures: the first United States clinical series using the deep lamellar endothelial keratoplasty procedure

PURPOSE: To report the 6- and 12-month results of the first United States clinical series of deep lamellar endothelial keratoplasty (DLEK) in the treatment of endothelial dysfunction. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Eight eyes of eight patients with corneal edema from Fuchs' dystrophy and pseudophakia. METHODS: A 9.0-mm limbal, scleral, partial-depth incision provided access for a deep lamellar corneal pocket dissection. A 7.5- to 8.0-mm posterior lamellar disc of recipient tissue was then excised and replaced through the pocket with a same size donor disc containing healthy endothelium. A temporary air bubble in the anterior chamber was used for donor tissue adherence, and no surface corneal incisions or sutures were necessary. MAIN OUTCOME MEASURES: Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction astigmatism, TMS-1 topography, ultrasonic pachymetry, Orbscan topography, and endothelial cell density were evaluated. Intraoperative and postoperative complications are reported. RESULTS: At 6 and 12 months after surgery, all eight corneas were clear and the grafts were healed in good position. At 6 months, the BSCVA varied between 20/30 and 20/70, the average change in astigmatism from before surgery was +1.13 diopters (D; +/-1.50 D), the average change in corneal power was -0.4 D (+/-1.7 D), the average pachymetry was 648 micro m (+/-134 micro m), and the average endothelial cell count was 2290 cells/mm(2) (+/-372 cells/mm(2)). At 12 months, three of the four eyes reaching this time gate were 20/40 or better, with a change in astigmatism from before surgery of only +0.81 D (+/- 0.55 D), a corneal power change of -1.3 D (+/- 0.4 D), and an endothelial density of 2409 cells/mm(2) (+/- 154 cells/mm(2)). One of the original nine eyes entered into this study required conversion to standard penetrating keratoplasty as a result of a microperforation during recipient pocket dissection and has experienced no ill effects. CONCLUSIONS: The DLEK procedure, with its absence of corneal surface incisions and sutures, is a safe procedure that preserves the normal corneal topography, minimizes astigmatism and corneal power changes, and provides a healthy donor endothelial cell count and function. If interface optical clarity can be maintained, then this technique offers considerable advantages over penetrating keratoplasty in the treatment of endothelial dysfunction.     

Spontaneous resolution of partial donor disk dislocation after deep lamellar endothelial keratoplasty

PURPOSE: We report a case of spontaneous resolution of donor disk partial dislocation after deep lamellar endothelial keratoplasty (DLEK). DESIGN: Case report. METHODS: A 70-year-old male with right pseudophakia bullous keratopathy underwent DLEK. Postoperatively, a partial dislocation of inferior donor disk was noted. Repositioning surgery with gas tamponade was performed. RESULTS: The interfacial separation remained after gas tamponade. Two weeks later, corneal edema subsided, and there was a reduction in interfacial separation. One month after DLEK, donor disk spontaneously attached to recipient corneal bed. At the six-month follow-up, astigmatism was 1.75 diopters. Specular microscopy showed endothelial counts of 1520 cells/mm(2). Spectacle-corrected visual acuity improved to 6/15. CONCLUSIONS: Partial dislocation of donor disk after DLEK has a possibility of spontaneous resolution, even after a failed attempt at gas tamponade.     

Initial results of small incision deep lamellar endothelial keratoplasty (DLEK)

PURPOSE: To evaluate the results of replacing the posterior stroma and endothelium, using small incision deep lamellar endothelial keratoplasty (DLEK) surgical technique, in patients with corneal endothelial dysfunction. DESIGN: Noncomparative case series. METHODS: Fifteen eyes of 15 patients (six males and nine females) with endothelial dysfunction were included in this study. Through a 5-mm scleral incision, a deep lamellar pocket was created across the cornea, followed by excision of an 8.0-mm disk of posterior lamellar corneal tissue. Same size lamellar donor disk was prepared and placed in position without the need of suture fixation. Best spectacle-corrected visual acuity (BSCVA), refraction, endothelial cell density, corneal topography, and corneal thickness were analyzed. RESULTS: Average BSCVA preoperative was 20/200 (range 20/40 to hand movements (HM)), improving to 20/50 (range 20/20 to 20/120) at a mean follow-up of 7.2 months. Average refractive astigmatism at last follow-up was 1.46+/-1.21 diopters (range, 0 to 4 diopters). Preoperative average donor endothelial cell density was 2047+/-311 cells/mm2, and that at last follow-up was 1732+/-514 cells/mm2. Preoperative average pachymetry was 801.4+/-211.3 microm, improving to 553+/-90.4 microm at last follow-up. CONCLUSIONS: Initial results with small incision DLEK procedure indicate that it is a safe procedure that provides healthy donor endothelial cell count and function postoperatively, with encouraging visual results.     

Endothelial keratoplasty using donor tissue not suitable for full-thickness penetrating keratoplasty

PURPOSE: To evaluate the use of corneal donor tissue deemed unsuitable for full-thickness penetrating keratoplasty (PK) for use in deep lamellar endothelial keratoplasty (DLEK) and to compare postoperative results to those of DLEK surgery using donor tissue that is suitable for PK. METHODS: Small-incision DLEK surgery was performed using 39 donor corneas unsuitable for PK. Thirty-five donors had anterior scars or opacities, 3 donors had pterygia within the 8-mm zone, and 1 had prior LASIK. All donor preparation was completed by manual stromal dissection. The DLEK surgical and postoperative courses were reviewed. Preoperative and 6-month postoperative results of this study group were compared with a control group consisting of the first 55 consecutive small-incision DLEK patients receiving donor corneas that had no criteria excluding them from use in PK. Four eyes in the study group and 1 eye in the control group had the confounding variables of the presence of an anterior-chamber lens or surgical vitrectomy with macular disease in the recipient eye. RESULTS: There was no significant difference in preoperative measurements of best spectacle-corrected visual acuity (BSCVA; P = 0.372), donor endothelial cell density (ECD; P = 0.749), or corneal topography [surface regularity index (SRI), P = 0.485; or surface asymmetry index (SAI), P = 0.154] between the 2 groups. For the patients receiving corneas deemed unacceptable for PK, at 6 months after surgery, the vision (P = 0.002) and corneal topography measurements improved significantly from before surgery (SRI, P < 0.001; SAI, P < 0.001), and there was no significant change in refractive astigmatism (P = 0.240). There was a significant difference in the vision at 6 months postoperatively between the overall study group and the control group, with the mean vision of the study group at 20/56 and the control group at 20/43 (P = 0.015). If eyes with known cystoid macular edema (CME) and vitrectomy are removed from each group, there is no significant difference in vision at 6 months between the study group and the control group (P = 0.110), with the average BSCVA of those receiving donor corneas unsuitable for PK equal to 20/48 (range, 20/25-20/200) and the average vision for those receiving PK-acceptable donor tissue equal to 20/43 (range, 20/20-20/80). The 6-month average refractive astigmatism of the study group was 1.12 +/- 0.99 D (range, 0.00-4.00 D), and the average endothelial cell count was 2064 +/- 396 cells/mm(2) (range, 1208-2957 cells/mm(2)). There was no significant difference in 6-month postoperative endothelial cell count (P = 0.443), refractive astigmatism (P = 0.567), or corneal topography (SRI, P = 0.332; SAI, P = 0.110) in study patients who received corneas unsuitable for PK compared with control patients who received corneas suitable for PK. CONCLUSIONS: Endothelial keratoplasty such as DLEK surgery with manual donor preparation broadens the donor pool by enabling corneas that cannot be used for PK to be used for selective endothelial transplantation without deleterious postoperative results.     

Endothelial replacement without surface corneal incisions or sutures: topography of the deep lamellar endothelial keratoplasty procedure

PURPOSE: To evaluate the immediate postoperative corneal topography after the deep lamellar endothelial keratoplasty procedure. METHODS: Eight eye bank eyes underwent deep lamellar endothelial keratoplasty through a 9.0-mm limbal incision replacing the central 7.0 mm of posterior stroma and endothelium through the lamellar pocket wound. Orbscan topography was performed before and after surgery, and simulated keratometry readings and central corneal diopter power were recorded. The change in astigmatism and corneal power from preoperative to postoperative readings was then determined. RESULTS: The net change in corneal astigmatism averaged 0.4+/-0.5 diopters (range, -0.1 to 1.1 diopters). The net change in corneal power averaged -0.2+/-0.4 diopters of flattening (range, -0.9 to +0.2 diopters). Neither the astigmatism nor the corneal power levels after this surgery were significantly different from the preoperative topography (p = 0.22 and 0.27, respectively). CONCLUSIONS: The deep lamellar endothelial keratoplasty procedure, with its absence of corneal surface incisions or sutures, has no significant effect on immediate postoperative corneal topography. The potential advantages of this procedure over penetrating keratoplasty in the treatment of endothelial dysfunction are considerable.     

Femtosecond laser-assisted corneal surgery

PURPOSE OF REVIEW: The femtosecond laser has potentially improved the safety and precision of creating corneal flaps in laser in situ keratomileusis (LASIK). This review focuses on recent advances in applying femtosecond laser technology to other corneal procedures. RECENT FINDINGS: The femtosecond laser is capable of cutting tissue at various depths and patterns with minimal collateral tissue injury. The laser can now be used to perform corneal pockets for ring segments, arcuate wedge-shaped resection in correction of high astigmatism, lamellar dissections in anterior lamellar keratoplasty, donor tissue preparation in Descemet's stripping endothelial keratoplasty, and shaped full-thickness keratoplasty. SUMMARY: Femtosecond laser-assisted corneal surgery may provide a more precise and safer approach to corneal surgery.     

Case report: femtosecond laser-assisted small incision deep lamellar endothelial keratoplasty

PURPOSE: To report two cases of femtosecond laser-assisted small incision deep lamellar endothelial keratoplasty (DLEK) for patients with corneal endothelial decompensation by Fuchs dystrophy and glaucoma METHODS: Femtosecond laser (IntraLase; IntraLase Corp., Irvine, CA) with 15 kHz of repetition rate, was used for a 9.5 mm diameter by 400 micrometer thickness donor corneal lamellar dissection. RESULTS: In Case 1, the graft was clear and compact without interface haze, Orbscan showed smooth and regular corneal surface, specular microscopy was unremarkable without sign of corneal endothelial damage, and Optical coherence tomography showed uniform graft well attached to recipient stroma with minimal interface reflection at 2 months postoperation. In Case 2, the graft was clear and compact with minimal interface haze at 1 month postoperation. Femtosecond laser-assisted small incision DLEK was safe and technically feasible in our cases; however, further evaluation is required to determine long-term effects.     

Deep lamellar endothelial keratoplasty: surgery in complex cases with severe preoperative visual loss

PURPOSE: This study was designed to report the use of deep lamellar endothelial keratoplasty (DLEK) in combination with other intraocular surgeries in the treatment of eyes with severe bullous keratopathy and visual loss. METHODS: DLEK surgery was performed in six patients with severe bullous keratopathy and preoperative vision with a range of between count fingers and light perception only. DLEK was combined with vitrectomy and placement of a ciliary sulcus sutured intraocular lens in four patients and with cataract surgery in one patient. Two patients with vitreoretinal disease underwent pars plana vitrectomy within only 4 months after the DLEK donor tissue had been placed. Graft clarity, Snellen visual acuities, refractive astigmatism, endothelial cell counts, and corneal topography were prospectively measured at 6 and 12 months postoperatively. RESULTS: At 6 months after DLEK surgery, all grafts were clear and vision improved in all patients. Best spectacle-corrected visual acuity improved from count fingers level (or worse) before surgery to a range of 20/40 to 20/200 after surgery. Average refractive astigmatism at 6 months was 2.0 diopters (range, 0.50-4.00 diopters). The average postoperative endothelial cell count was 1,679 +/- 380 (range, 1,200-2,298) cells/mm at 6 months and 1,449 +/- 365 (range, 1,105-2,043) cells/mm at 12 months. Vitreoretinal surgery subsequent to graft placement did not affect corneal clarity or dislodge the grafted tissue. CONCLUSIONS: DLEK surgery can be used in cases with severe visual loss caused by bullous keratopathy with transfer of healthy donor endothelium, clearing of the central cornea, and restoration of useful vision. DLEK also can be successfully combined with other intraocular surgeries such as vitrectomy, intraocular lens exchange, and sutured intraocular lens surgery. The DLEK graft can tolerate subsequent intraocular surgery performed as early as 3 months after placement of the donor tissue.     

Femtosecond laser posterior lamellar keratoplasty: a laboratory model

PURPOSE: To evaluate feasibility of femtosecond laser application in posterior lamellar keratoplasty. METHODS: To evaluate the laser's effectiveness through opaque corneas, anterior corneal caps were resected from opaque corneas induced with 80% acetone solution. To evaluate the femtosecond laser posterior lamellar keratoplasty surgical procedure, human corneoscleral rims were mounted on an artificial anterior chamber. After corneal pachymetry, the femtosecond laser was used to create a 6-mm-diameter, 200-microm-thick endostromal lenticule. Access to the lenticule was provided by a small perilimbal surface opening, also created by the laser. The lenticule was removed using a pair of corneal forceps. A donor lenticule of similar dimensions was created, its endothelial surface coated with viscoelastic, inserted, and positioned on the recipient bed. Two sutures were placed to seal the small surface opening. RESULTS: The femtosecond laser produced an effective and smooth dissection through opaque corneas even at deeper settings. Graft transplantation was fairly simple and effective. CONCLUSION: Femtosecond laser posterior lamellar keratoplasty is a procedure that may provide an alternative to penetrating keratoplasty or the technically challenging manual posterior lamellar keratoplasty.     

Modified automated lamellar therapeutic keratoplasty for keratoconus: a new technique

PURPOSE: To describe a modified automated lamellar therapeutic keratoplasty (ALTK) technique for the treatment of keratoconus. METHODS: The ALTK procedure was modified to include the use of a Hanna trephine system to control donor and recipient diameters and was performed in 2 stages. The recipient corneal lamellar bed was first prepared by creating a laser in situ keratomileusis (LASIK) flap at a preset depth that was left to heal over. The second stage involved the use of a Hanna trephination system to perform central trephination within the lamellar flap and transplantation of a donor lamellar graft that was fashioned to precisely match the recipient corneal bed, again using the Hanna donor punch to create a central trephination within the lamellar button obtained with the ALTK unit. RESULTS: The modified ALTK procedure effectively treated a patient with moderate keratoconus with a best-corrected visual acuity of 20/80, despite rigid gas-permeable contact lenses. Postoperatively, there was a significant reduction in the irregular astigmatism, and visual acuity improved to 20/25. There were no complications, and the ALTK interface remained clear throughout the 20-month follow-up period. CONCLUSIONS: ALTK combined with Hanna trephination enables precise control of both depth and diameter of lamellar dissection during surgery, removes the need for any form of manual dissection, and may therefore improve optical and visual outcomes in lamellar keratoplasty.     

A laboratory model for microkeratome-assisted posterior lamellar keratoplasty utilizing a running graft suture and a sutureless hinged flap

PURPOSE: To evaluate changes in anterior corneal curvature and graft stability with different sized donor buttons in a laboratory model of posterior lamellar keratoplasty. METHODS: Thirty-six human eye bank corneas (18 donors and 18 recipients) were mounted on an artificial anterior chamber. A manual microkeratome was used to create a hinged anterior lamellar keratectomy. A 7.0-mm diameter posterior lamellar disk (posterior stroma, Descemet's membrane, and endothelium) was then trephinated from the recipient cornea. Three different sizes (7.0, 7.25, and 7.5 mm) of donor buttons were compared. They were sutured into the recipient bed with a running 10-0 nylon suture and covered by the host corneal flap. The flap was replaced without sutures. The resulting endokeratoplasty was analyzed by computerized videokeratography and tonometry. RESULTS: Regular postoperative astigmatism was present in all cases. There was an average increase in astigmatism of 1.47 +/- 1.49 diopters (D) postoperatively. The mean change in the average keratometry readings was -5.12 +/- 6.12 D. The grafts and flaps maintained watertight seals with average leak pressures of 66.9 +/- 46.4 mm Hg. Although donor buttons oversized by 0.5 mm had the least change in average keratometry reading, those oversized by 0.25 mm had the best stability at high pressure. All groups had little change in astigmatism. CONCLUSION: The optimal sized button of those tested would be either oversized by 0.25 or 0.5 mm. This new surgical technique may result in lower risk of high and irregular astigmatism in the management of corneal endothelial disorders.     

Femtosecond-laser-assisted Descemet's stripping endothelial keratoplasty

To our knowledge, we describe the first patient with pseudophakic bullous keratoplasty treated with femtosecond-laser-assisted endothelial keratoplasty. A 5.5 mm corneoscleral tunnel incision was made; after Descemet's membrane was stripped, an 8.0 mm posterior lamellar corneal disk prepared with a femtosecond laser was inserted into the anterior chamber against the recipient cornea without the use of corneal sutures. Four months postoperatively, the posterior corneal disk was clear and the induced astigmatism was 2.1 diopters, demonstrating a functional corneal endothelial layer. The femtosecond laser offers a new surgical approach for minimally invasive endothelial keratoplasty in corneal endothelial disorders.     

小切口无缝线深板层角膜内皮移植术的疗效观察

目的探讨小切口无缝线深板层角膜内皮移植术的手术方法、临床疗效及并发症的预防与处理。方法对9例（9只眼）大泡性角膜病变患者行小切口无缝线深板层角膜内皮移植术,其中6例联合前段玻璃体切割术。术后观察植片与植床贴合情况、植片移位的发生和处理。随访3～5个月,观察视力、植片透明度、角膜曲率、角膜散光及角膜内皮细胞密度。结果8例患者植片与植床贴合良好,1例患者术后第1天植片移位,经再次复位后贴合良好。6例患者不同程度提高视力,3例患者因术前长期高眼压,术后视力不提高。9例患者植片均透明,角膜曲率（43．96±3．38）D,角膜散光度数（3．32±1．20）D,角膜内皮细胞密度（2124±278）个／mm^2,未出现严重并发症。结论与穿透性角膜移植或板层角膜瓣下深板层角膜内皮移植术比较,小切口无缝线深板层角膜内皮移植术治疗大泡性角膜病变更有优势,有望成为治疗该病的手术方式之一。     

Femtosecond laser-assisted intracorneal keratoprosthesis implantation: a laboratory model

PURPOSE: To demonstrate femtosecond laser-assisted intracorneal keratoprosthesis implantation and determine the mechanical stability as a function of intraocular pressure. METHODS: Eight human corneoscleral rims were mounted on an artificial anterior chamber. The femtosecond laser microkeratome was used to create a 2.5-mm diameter posterior corneal cap. A 7.2-mm-diameter lamellar stromal pocket was then created at mid-corneal depth. Finally, a 6-mm arc opening to the corneal surface was created at the periphery of the lamellar cut. The posterior lenticule was removed using corneal forceps and a 7.0-mm biopolymer keratoprosthesis was inserted into the stromal pocket. The surface wound was sealed using two 10-0 nylon sutures. A 3.0-mm anterior corneal opening was trephined to expose the keratoprosthesis. Intrachamber pressure was raised until wound leak was observed. RESULTS: Seven of the 8 implants withstood pressures of at least 135 mm Hg without implant extrusion. CONCLUSION: Femtosecond laser corneal dissection provides an alternative to more challenging manual dissection methods for keratoprosthesis implantation. Use of the femtosecond laser microkeratome will further refine keratoprosthesis surgical technique and may allow rapid and easy execution of the surgery.     

Big-bubble deep anterior lamellar keratoplasty assisted by femtosecond laser in children

To report the early results of big-bubble deep anterior lamellar keratoplasty assisted by femtosecond laser in children. Five eyes of 5 pediatric patients were enrolled in the study; 3 had keratoconus and 2 corneal opacities. An IntraLase 60 KHz femtosecond laser (Abbott Medical Optics, Inc) was used to create mushroom incisions on both donor and recipient corneas. All patients were evaluated for best-corrected visual acuity, spherical equivalent, refractive astigmatism, keratometric astigmatism, mean K value, and corneal thinnest point. The big bubble was always achieved, and all eyes were treated successfully without intraoperative complications. The follow-up was of 10 months. At 10 months (at least 3 months after complete suture removal), the mean postoperative best-corrected visual acuity was 20/30 (range, 20/25 to 20/30), mean spherical equivalent was -1.8 ± 1.2 diopters (D) (range, -0.25 to 1.25 D), mean refractive astigmatism was 1.8 ± 1.4 D (range, 0 to 4.0 D), mean keratometric astigmatism was 5.1 ± 2.1 D (range, 3.5 to 8.59 D), mean K value was 46.2 ± 0.8D, and mean corneal thinnest point was 581 ± 46 μm (range, 511-638 μm). Our early findings suggest that the big-bubble technique in deep anterior lamellar keratoplasty assisted by femtosecond laser is safe and effective also in pediatric patients in the attempt to decrease the rejection percentage, improve the refractive outcome, and then provide an antiamblyopic effect.     

"Top hat"-shaped penetrating keratoplasty using the femtosecond laser

PURPOSE: To determine the feasibility of using a modified femtosecond laser to perform penetrating corneal resections. DESIGN: Controlled laboratory study. METHODS: Fourteen corneoscleral rims were mounted on an artificial anterior chamber. Eight underwent traditional penetrating keratoplasty (PKP) and six underwent "top hat"-shaped PKP using a femtosecond laser. Wound leakage pressure and induced astigmatism were compared between the two groups. RESULTS: Deep corneal resection with the femtosecond laser was feasible. Wound leakage occurred at 38 +/- 11 mm Hg in the traditional PKP eyes and at 240 +/- 69 mm Hg in the laser-shaped PKP groups. Initial induced astigmatism was 3.76 +/- 0.82 diopters and 3.46 +/- 1.36 diopters in the traditional and shaped PKP groups, respectively. CONCLUSIONS: Shaped PKP using the femtosecond laser is feasible and provides superior incision integrity compared to traditional PKP. Initial induced astigmatism is dominated by suture effects.     

角膜后弹力层剥除内皮移植术治疗大泡性角膜病变的初步疗效观察

目的 探讨角膜后弹力层剥除内皮移植手术的适应证、手术方法以及对大泡性角膜病变的疗效与并发症的处理.方法 非随机回顾性系列病例研究.选择2006年9月至2007年10月于中山大学中山眼科中心住院的8例(8只眼)大泡性角膜病变患者行角膜后弹力层剥除内皮移植术.术中剥除患眼角膜中央部直径7.75 mm的后弹力层和病变的内皮层,再将植床周边部基质表面刮粗糙,然后按常规角膜内皮移植术的方法植入内皮植片.术后观察植片与植床贴合和植片移位等情况.随访3～9个月,记录患者视力、植片透明度、角膜散光及内皮细胞密度.结果 8例患者术后植片与植床贴合良好,未出现植片移位.术后第1天,1例患者出现继发性闭角型青光眼,术后48 h后缓解.8例患者术后植片透明,术前存在眼痛的6例患者术后眼痛缓解.8例患者术后视力均提高,最好矫正视力为0.3～0.7,平均角膜散光度数为(1.90±0.70)D,平均内皮细胞密度为(2014±192)个/mm2.结论 与深板层角膜内皮移植术比较,角膜后弹力层剥除内皮移植术的操作较简单,对受体角膜和前房的创伤更小.术中将植床周边部基质表面刮粗糙,可有效预防术后植片移位.     

Five-millimeter-incision deep lamellar endothelial keratoplasty: one-year results

PURPOSE: To evaluate visual acuity, topography, and endothelial cell density 1 year after deep lamellar endothelial keratoplasty (DLEK) for endothelial dysfunction. METHODS: This is a prospective, comparative, interventional case series. Thirty-five eyes of 35 patients who had undergone DLEK with a 5-mm incision and had a minimum of 1-year follow-up were included. Main outcome measures were best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), astigmatism, topographic regularity and symmetry, and endothelial cell density. RESULTS:: One year postoperatively, BSCVA was 0.33 +/- 0.12 (mean, 20/60; range, 20/40-20/400) compared with 0.15 +/- 0.15 preoperatively (mean, 20/200; range, 20/70-20/800). Six patients did not reach an acceptable visual acuity and were not included in the mean BSCVA, 2 had a primary failure, and the others had preexisting glaucoma or macular disease. Spherical equivalent was -0.04 +/- 1.2 D, refractive astigmatism was 1.76 +/- 1.69 D, surface regularity index was 0.97 +/- 0.54, and surface asymmetry index was 1.25 +/- 0.78 1 year after surgery. Mean endothelial cell count from the donor was 2904 +/- 559 (range, 4694-2111) and 1 year after surgery was 1595 +/- 662 (range, 702-3040), equating to 45% cell loss (range, 15%-77%). CONCLUSIONS: DLEK is a newer method to replace the endothelium in patients with Fuchs dystrophy. Results showed minimal astigmatism, good topographic parameters, and acceptable visual acuity. Endothelial cell loss at 1 year was significant.     

Preliminary clinical results of posterior lamellar keratoplasty through a sclerocorneal pocket incision

PURPOSE: To report the preliminary results of a surgical technique for transplantation of posterior corneal tissue through a sclerocorneal pocket incision for corneal endothelial disorders. DESIGN: Retrospective, noncomparative, interventional cases series. PARTICIPANTS AND INTERVENTION: In seven sighted human eyes, a deep stromal pocket was created across the cornea through a 9.0-mm superior scleral incision. A 7.0- or 7.5-mm diameter, posterior lamellar disc was excised and replaced by a 'same size' donor posterior disc, without suture fixation. The scleral incision was sutured. MAIN OUTCOME MEASURES: Intra- and postoperative complications, best spectacle-corrected visual acuity, keratometry, topography, biomicroscopy, pachymetry, and endothelial cell density were evaluated. RESULTS: Six to 12 months after surgery, all transplants were clear and in position. Best spectacle-corrected visual acuity was limited by preexisting maculopathies in two eyes and varied from 20/80 to 20/20. Postoperative astigmatism averaged 1. 54 diopters (D; standard deviation [SD] +/- 0.81 D), pachymetry averaged 0.49 mm (SD +/- 0.09 mm), and postoperative endothelial cell density averaged 2520 cells/mm(2) (SD +/- 340 cells/mm(2)). In one eye, a microperforation occurred during stromal pocket dissection so that the procedure was converted into a penetrating keratoplasty. CONCLUSIONS: Posterior lamellar keratoplasty through a sclerocorneal pocket incision is a feasible surgical approach to manage corneal endothelial disorders.