Deep lamellar keratoplasty for acanthamoeba keratitis

PURPOSE: To describe deep lamellar keratoplasty (DALK) as a surgical alternative to penetrating keratoplasty in the management of unresponsive Acanthamoeba keratitis. METHODS: Interventional case report. We performed DALK in a patient with Acanthamoeba keratitis unresponsive to intensive antimicrobial therapy. A modified form of the Anwar big-bubble technique, with total corneal stromal removal down to Descemet membrane, was successfully performed without entry into the anterior chamber. Subsequent delay in graft epithelialization relating to ocular surface toxicity from prolonged antiacanthamoebal topical therapy required a secondary amniotic membrane patch graft. RESULTS: No recurrence of Acanthamoeba infection occurred after surgery. Reepithelialization after the amniotic membrane patch graft was successful, and full visual recovery occurred, resulting in a best-corrected visual acuity of 20/20. CONCLUSIONS: DALK with total removal of infected stromal tissue may be performed in medically unresponsive cases of Acanthamoeba keratitis, which ordinarily may require penetrating keratoplasty. Advantages of DALK in infectious keratitis include less risk of intraocular entry of infectious organisms at the time of surgery and the potential for improved graft survival rates caused by less endothelial rejection and failure.