完全钝性基质层间分离的深板层角膜移植术

目的 介绍一种虹膜恢复器辅助的完全钝性基质层间分离的深板层角膜移植术,并评估应用该术式治疗各种角膜病的有效性和安全性.方法 通过激光共聚焦显微镜检查,选择角膜病变深度未达后弹力层,内皮功能正常的各类角膜病患者35例35只眼.通过虹膜恢复器辅助的完全钝性基质层间逐层分离的方式行深板层角膜移植,并对其疗效进行观察、分析.结果 35只眼中,2只眼(5.71%)有小的钝性撕裂,在保留少量深基质后均能继续完成手术;术后2只眼(5.71%)出现双前房,3d内均自行吸收;细菌和真菌性角膜溃疡术后均未复发.其中18只眼拆线后两周视力高于0.5(约占51.4%),25只眼高于0.3(约占71.4%).术后角膜地形图散光呈现递减的趋势,角膜内皮细胞密度无明显下降.术后6个月角膜植片均透明愈合,无明显层间混浊.结论 通过虹膜恢复器辅助的基质层间钝性分离的深板层角膜移植术是一种安全有效的手术方式.激光共焦显微镜检查可活体检查角膜各层组织结构,可为深板层角膜移植术提供良好的客观依据.     

全厚植片深板层角膜移植术的临床应用研究

角膜病是最常见的致盲性眼病之一,角膜移植术是角膜盲最重要的复明手术。角膜移植术是用健康的角膜替代病变混浊的角膜,目的在于恢复患眼视力或治疗某些难治性角膜病变,有时也为了先改善患眼的角膜基地条件或改变患眼的屈光和美容而行此手术,主要包括穿透性角膜移植术和板层角膜移植术两种。其中板层角膜移植术是指用相应厚度的健康板层角膜取代病变板层角膜,用于治疗未累及角膜厚弹力层和内皮细胞层的角膜混浊、角膜变性和角膜营养不良,又可分为     

深板层角膜移植手术经验探讨

目的为提高手术成功率,探讨深板层角膜移植术的适应证及手术技巧。方法对内皮功能正常的角膜基质病变患者行深板层角膜移植术28只眼,术中采用角膜基质层间注入生理盐水或2%甲基纤维素分离方法,观察术中并发症、术后角膜透明度及术后视力提高等指标。结果19只眼术中未发生后弹力层穿孔,术后植片透明。术中发生后弹力层微或小穿孔9只眼,未行任何处理,其中有3只眼术后出现角膜植片轻度水肿、角膜层间有少量积液,经加压包扎及口服醋氮酰胺,积液在2周内逐渐吸收;另外6只眼术后前房形成良好,植片透明,无角膜层间积液。术后1年随访,28只眼中22只眼植片透明,6只眼角膜半透明。1只眼角膜被铁水烧伤后遗血管翳性混浊患者于术后8个月发生上皮型排斥反应,经药物治疗角膜逐渐恢复透明,无新生血管长入。15只眼最佳矫正视力达0.3～0.6,7只眼达0.1～0.3（含0.3）,6只眼达0.05～0.1。结论目前临床上相当部分用穿透性角膜移植治疗的内皮功能正常的角膜基质病变将可以被深板层角膜移植取代。只要掌握好手术适应证,提高手术操作技术,减少术中并发症及加强术后管理,可提高手术成功率。     

深板层角膜移植手术并发症及处理

目的 探讨深板层角膜移植手术的并发症及其处理.方法 回顾性病例研究.总结2005年1月至2012年2月在我科施行深板层角膜移植手术(274例)出现并发症的患者62例(62眼),分析术中和术后并发症,根据不同的并发症采用不同的处理方法.结果 术中并发后弹力层穿孔13眼;术后并发症中,双前房16眼,后弹力层皱褶13眼,继发性青光眼8眼,早期缝线松弛7眼,复发14眼,排斥4眼,角膜上皮愈合不良和基质溶解5眼,给予相应处理后均得到控制,恢复良好.结论 后弹力层穿孔和双前房是最常见的并发症.尽量减少及正确处理并发症,深板层角膜移植可以达到良好的远期效果.     

深板层角膜移植术

深板层角膜移植术(DLKP)是一种完全去除病变的角膜基质组织直至暴露后弹力层,再移植供体角膜组织的手术方法,适用于所有未累及后弹力层和内皮的角膜疾病。目前有多种DLKP手术方法,该手术具有穿通性角膜移植术和板层角膜移植术的优点,同时避免了两者的缺点。本文综述深板层角膜移植术的适应证、手术方法进展、并发症、优点及联合手术。     

深板层角膜移植术

深板层角膜移植术（DLKP）是一种完全去除病变的角膜基质组织直至暴露后弹力层，再移植供体角膜组织的手术方法，适用于所有未累及后弹力层和内皮的角膜疾病。目前有多种DLKP手术方法，该手术具有穿通性角膜移植术和板层角膜移植术的优点，同时避免了两者的缺点。本文综述深板层角膜移植术的适应证、手术方法进展、并发症、优点及联合手术。     

深板层角膜移植术治疗瘢痕期病毒性角膜炎

目的分析深板层角膜移植术治疗瘢痕期病毒性角膜炎的临床效果。方法临床诊断明确的瘢痕期病毒性角膜炎48例（48只眼）。均有不同程度及大小的角膜白斑和基质层的新生血管,部分患眼伴有角膜基质水肿,视力均低于0．1。术前给予积极的局部和全身糖皮质激素和抗病毒治疗,然后行深板层角膜移植术,术后随访2～48个月,观察视力、植片透明度、复发率及术中术后并发症。结果3只眼术中发生后弹力层破裂,其中2只眼行前房注气术后植片与植床贴服良好,1只眼术中改为穿透性角膜移植术,其余45只眼均接受深板层角膜移植术,手术均顺利,1只眼术后1个月更换角膜植片,3只眼复发未及时随访治疗导致植片浑浊血管化,经治疗恢复透明,4只眼出现上皮型免疫排斥反应,经积极治疗后植片恢复透明。所有术眼视力均有不同程度的提高,最佳矫正视力≥0．25者13只眼,0．12～0．2者15只眼,≤0．1者20只眼。结论深板层角膜移植术可以比较有效地治疗瘢痕期病毒性角膜炎,后弹力层的瘢痕和皱褶是影响术后视力恢复的主要原因,因此对于瘢痕期病毒性角膜炎应早行手术治疗。     

深板层角膜移植治疗格子样角膜营养不良的疗效观察

目的 探讨深板层角膜移植治疗格子样角膜营养不良的临床效果.方法 对24例(32眼)视力明显受损的格子样角膜营养不良患者行深板层角膜移植术,术后随访6～ 36个月,观察视力和并发症.结果 术后最佳矫正视力0.3～0.6者12眼,0.7～0.9者16眼,1.0～1.2者4眼.并发症包括术中后弹力层穿孔4眼;术后一过性眼压升高2眼,后弹力层皱褶5眼.无发生排斥反应者.结论 深板层角膜移植术治疗格子样角膜营养不良安全有效.     

深板层角膜移植术后双前房的手术处理

角膜后弹力层脱离是深板层角膜移植术deep lamellar keratoplasty,DLK)的并发症之一,导致双前房形成。如双前房长期存在,植片将水肿、混浊。本研究观察3例DLK术后出现双前房的患者,并进行了3种不同方式的手术处理,报告如下。1临床资料病例1,男,65岁,右眼角膜斑翳。采用直接开放式完成深板层剖切,暴露后弹力膜,10-0尼龙线缝合植片时植床边缘4点钟处房水渗漏。为预防术后双前房形成,前房注入消毒空气至眼压T 1,加压包扎。次日检查发现气泡约1/2残留,位于角膜层间,后弹力膜贴向虹膜面。为消除层间气泡及积液,避免角膜内皮功能进一步损害,即…     

深板层角膜移植术治疗急性期圆锥角膜的探讨

目的 观察深板层角膜移植术治疗急性期圆锥角膜的手术时机及临床效果.方法 总结自2008年9月至2009年9月于邢台眼科医院住院的急性期圆锥角膜患者8例,均于发病后2～3周采用深板层角膜移植术治疗,术后随访观察6～12个月,观察角膜植片的透明度及视力情况.结果 8例患者中,术前裸眼视力4例为手动,4例为眼前指数,矫正均不提高;术后裸眼视力为0.2～0.5的6例,≥0.6的2例,术中发现后弹力层裂孔呈裂隙状;术后6例大部分裂孔已愈合,角膜植片透明;2例裂孔较大者(尚有约1mm未愈合)术后第3天发现少许层间积液,植片基质层轻度水肿,经前房补气及包扎后层间积液吸收,角膜植片恢复透明;全组病例后弹力层破裂处无明显混浊.结论 深板层角膜移植术治疗急性期圆锥角膜可以取得较好的临床效果.     

Deep lamellar keratoplasty using viscoelastic dissection

We describe a technique for performing deep lamellar keratoplasty using viscoelastic dissection. Deep lamellar dissections of the cornea using viscoelastic substances (sodium hyaluronate) were performed on 4 eyes of 4 patients. One patient with keratoconus and another with corneal scarring underwent lamellar keratoplasty using the technique as the sole procedure for visual rehabilitation. Two patients (2 eyes) with opaque corneas underwent deep lamellar dissection with removal of stromal tissue to allow visualization of the anterior segment structures prior to penetrating keratoplasty, thereby facilitating separation of iridocorneal adhesions as the Descemet membrane was incised. Deep lamellar dissection was performed without complications related to the procedure in all 4 eyes. The 2 lamellar grafts cleared completely, and both eyes achieved excellent visual acuity with spectacle correction. In the other 2 eyes, deep lamellar dissection provided clear visualization of anterior segment structures during incision of the Descemet membrane. Deep lamellar dissection using viscoelastic substances is a useful technique during lamellar keratoplasty.     

Deep lamellar keratoplasty in severe ocular surface disease

PURPOSE: To demonstrate the efficacy and safety of deep lamellar keratoplasty(DLKP) in the treatment of corneal opacity in severe ocular surface disease. METHODS: A total of 12 eyes of 11 patients were analyzed in this retrospective case series. The original diseases were Stevens Johnson syndrome (SJS : 3 eyes), ocular ciccatricial pemphigoid(OCP : 2 eyes), thermal burns (2 eyes), limbal deficiency due to unknown cause (2 eyes), and corneal scarring due to trachoma (3 eyes). Cases with total limbal deficiency (6 eyes) were also treated with secondary or simultaneous limbal transplantation. Cataract surgery was also performed in 4 eyes following DLKP. RESULTS: DLKP was successfully done in all cases. One case with SJS experienced an immunological rejection against the limbal graft. Two eyes with SJS eventually developed ulcers that required therapeutic penefrating keratoplasty. Visual improvement was observed in 9 out of 12 eyes, of which 2 cases maintained a corrected visual acuity of 0.1 despite conjunctivalization of the ocular surface. CONCLUSION: DLKP is an effective means to treat stromal opacity in patients with ocular surface disease.     

Big-bubble deep anterior lamellar keratoplasty for post-keratitis and post-traumatic corneal stromal scars

Background: Evaluation of outcomes of big‐bubble deep anterior lamellar keratoplasty in cases with post‐keratitis and post‐traumatic corneal scars. Design: Interventional case series. Participants: Patients with corneal stromal scarring secondary to healed infectious keratitis or trauma were recruited from the Corneal Clinic of the M. M. Joshi Eye Institute, Karnataka, India between August 2007 and December 2009. Methods: All patients underwent big‐bubble deep anterior lamellar keratoplasty surgery. Main Outcome Measures: Best‐corrected visual acuity, as well as intra‐ and postoperative complications. Results: Big‐bubble deep anterior lamellar keratoplasty was performed in 36 patients (25 males, 11 females) with post‐infectious keratitis (n = 22) and post‐traumatic (n = 14) corneal stromal scars sparing the Descemet's membrane and endothelium. Mean age was 39.7 ± 11.3 years (range: 22–58 years). Although a big bubble was achieved in all eyes (100%), intraoperative perforation of the Descemet's membrane occurred in six eyes (16%) during stromal dissection. Two cases required conversion to penetrating keratoplasty. A double anterior chamber occurred in the immediate postoperative period in three cases (8.3%). Raised intraocular pressure was seen in one eye. Mean preoperative best‐corrected visual acuity (0.03 ± 0.04) improved significantly at the end of 6 months follow‐up postoperatively (0.43 ± 0.20; P < 0.01, Wilcoxon signed‐ranks test). Corneal stromal graft rejection was noted in two cases (5.5%) during the first 3 months after surgery. Graft failure occurred in two cases (5.5%). Conclusions: Deep anterior lamellar keratoplasty using the big‐bubble technique is a viable option in cases with post‐infectious keratitis and post‐traumatic corneal stromal scarring with normal Descemet's membrane and endothelium.     

Observation on ultrastructure and histopathology of cornea following femtosecond laser-assisted deep lamellar keratoplasty for acute corneal alkaline burns

AIM: To demonstrate the changes in ultrastructure and histopathology of the cornea in acute corneal alkaline burns after femtosecond laser-assisted deep lamellar keratoplasty. METHODS: The New Zealand white rabbits treated with alkaline corneal burn were randomized into two groups, Group A (16 eyes) with femtosecond laser-assisted deep lamellar keratoplasty 24h after burn and Group B (16 eyes) without keratoplasty as controls. All eyes were evaluated with transmission electron microscopy (TEM) at 1, 2, 3, and 4wk follow-up, then all corneas were tested by hematoxylin and eosin staining histology. RESULTS: The corneal grafts in Group A were transparent, while those in Group B showed corneal stromal edema and loosely arranged collagen fibers. One week after treatment, TEM revealed the intercellular desmosomes in the epithelial layers and intact non-dissolving nuclei in Group A. At week 4, the center of the corneas in Group A was transparent with regularly arranged collagen fibers and fibroblasts in the stroma. In Group B, squamous cells were observed on the corneal surface and some epithelial cells were detached. CONCLUSION: Femtosecond laser-assisted deep lamellar keratoplasty can suppress inflammatory responses, prevent toxic substance-induced injury to the corneal endothelium and inner tissues with quicker recovery and better visual outcomes.     

Double anterior chamber deep lamellar keratoplasty: case report

PURPOSE AND METHODS: We report a case in which, although we planned to perform a penetrating keratoplasty for corneal stromal opacity with normal corneal endothelium, the host's Descemet's membrane became inadvertently detached and the operation resulted in double anterior chamber deep lamellar keratoplasty (DLKP). RESULT: After surgery, the patient's corrected visual acuity was 20/30. CONCLUSION: Double anterior chamber DLKP is safe and valuable.     

Excimer laser lamellar keratoplasty

Purpose: To evaluate a procedure using the excimer laser to perform lamellar keratoplasty to treat deep corneal scars in the central optical zone. To determine if excimer laser can safely prepare a smooth surface for the host bed and the donor button, assess the interface opacity and evaluate the effects of the ablation on the recipient's endothelial surface with the deeper ablation.
Methods: Nineteen rabbits underwent an excimer laser lamellar keratoplasty in one eye. The rabbits were followed for 9 to 12 weeks until they were sacrificed.
Results: Little opacity developed at the graft-host interface and scanning electron microscopy of the endothelial surface showed little difference between the treated and untreated areas or the endothelium of the untreated eyes.
Conclusions: Our results suggest that the use of the excimer laser to treat corneas with deep stromal scars and normal endothelium is feasible. However, we have not proved that this technique will give a better result than conventional lamellar dissection methods.     

Deep lamellar keratoplasty for various corneal lesions

PURPOSE: To evaluate the efficacy and safety of deep lamellar keratoplasty (DLK) as a method for treating various diseases of corneal stroma with unaffected endothelium. METHODS: DLK was performed in 31 eyes of 31 patients with corneal stroma opacity without endothelial abnormalities. Surgical procedures included deep removal of corneal stroma 7.5 mm in diameter with the use of viscoelastic or 0.02% trypan blue solution, exposing Descemet membrane in the central area of about 5 mm across including the area of pupil, and grafting a corneal lenticule. In three cases of postinflammatory stromal scars with coexisting limbal stem cell deficiency, limbal stem cell grafting was additionally performed. Main outcome measures were best-corrected visual acuity (BCVA) and postoperative astigmatism. RESULTS: Intraoperative perforation of Descemet membrane with the necessity of converting the procedure into penetrating keratoplasty occurred in five cases (16.1%) and one patient underwent penetrating keratoplasty on the seventh day after DLK due to persistent double anterior chamber. These six patients were excluded from the study. Postoperative BCVA ranged from 0.1 to 1.0 and astigmatism from 1.2 to 4.7 D. Postoperative complications were loose sutures, ocular hypertension, Descemet membrane detachment, and corneal melting. CONCLUSIONS: DLK is an effective procedure for treating various diseases of corneal stroma with unaffected endothelium. This technique as an extraocular procedure seems to be the treatment of choice in mentally retarded patients.     

Randomized clinical trial of deep lamellar keratoplasty vs penetrating keratoplasty

PURPOSE: To prospectively compare the safety and efficacy of deep lamellar keratoplasty (DLKP) and penetrating keratoplasty (PKP). DESIGN: Prospective, randomized clinical trial. METHODS: Consecutive 26 eyes of 24 patients who had stromal opacity without endothelial abnormalities were randomly assigned to either PKP or DLKP. Best-corrected visual acuity (BCVA), contrast visual acuity, glare test, intraocular pressure, corneal topography, endothelial density, and pachymetry were measured before and after surgery. RESULTS: Two eyes in the DLKP had rupture of the Descemet membrane and one of the eyes developed endothelial decompensation. One eye in the PKP group showed decreases in vision due to secondary glaucoma. None of the eyes developed immunologic rejection. The PKP group showed a tendency of faster recovery in BCVA than the DLKP group, but the difference was not statistically significant. Contrast visual acuity, glare test, and corneal topography did not show significant differences between the two groups. The intraocular pressure was significantly higher at 12 months in the PKP group (P =.004), but not in the DLKP group (P =.41) compared with preoperative values. While the PKP group showed progressive decrease in endothelial density over 24 months, this was not observed in the DLKP group after surgery. Difference in endothelial density at 24 months reached statistical significance (P =.04). CONCLUSIONS: We found that DLKP was superior to PKP in its safety such as continuous decreases of endothelium or increases in intraocular pressure. However, endothelial damage can also occur in DLKP, especially in cases of intraoperative Descemet membrane rupture. With the development of easier surgical techniques, DLKP may be a first choice of keratoplasty in most eyes without endothelial abnormalities.     

Deep lamellar keratoplasty by deep parenchyma detachment from the corneal limbs

AIM: To improve the deep lamellar keratoplasty technique. METHOD: For the easy and reliable perfomance of deep lamellar keratoplasty (DLKP), detachment of Descemet's membrane through the corneal limber flap was improved. To expose Descemet's membrane, the parenchyma was detached by hydrodelamination through a sclerocorneal flap made in the corneal limbs. The parenchyma was removed after the pseudochamber between it and Descemet's membrane was maintained with viscoelastic material. The corneal graft was placed with a running suture. 22 eyes were treated. RESULTS: Complete exposure of Descemet's membrane was obtained in 20 of the 22 eyes (91%). The membrane was perforated in five of the 22 eyes (23%) during surgery, and two of the 22 eyes (9%) were converted to penetrating keratoplasty. These two eyes developed keratoconus after acute corneal hydrops. CONCLUSION: Compared with the conventional procedure, this new method provides easy, reliable exposure of Descemet's membrane.