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Acta Ophthalmologica 2008

Longterm results of deep lamellar keratoplasty using grafts with endothelium
Shiro Higaki,1 Yuichi Hori,2 Naoyuki Maeda,2 Hitoshi Watanabe,2 Yoshitsugu Inoue3 and Yoshikazu Shimomura1
1 Department of Ophthalmology, Kinki University School of Medicine, Osaka, Japan 2 Department of Ophthalmology, Osaka University Medical School, Osaka, Japan 3 Division of Ophthalmology, Faculty of Medicine, Tottori University, Tottori, Japan

ABSTRACT. Purpose: To report the longterm results of deep lamellar keratoplasty (DLK) using grafts with their own endothelia. Methods: Fourteen eyes of 14 patients underwent DLK using grafts with endothelium. The average follow-up was approximately 80.0 months. Preoperative diagnoses included: corneal leukoma (five eyes); gelatinous drop-like corneal dystrophy (three eyes); Avellino corneal dystrophy (two eyes); corneal perforation (two eyes); corneal mucopolysaccharidosis (one eye), and keratoconus (one eye). Results: Corrected visual acuity was improved in 13 eyes (93%), but ruptures of Descemet’s membrane occurred in six eyes (43%) and a double anterior chamber was found in five eyes (36%) postoperatively. Despite this, all grafts remained clear as a result of their functioning endothelia. Conclusions: Deep lamellar keratoplasty using a graft with its own endothelium is a safe and valuable procedure with flexibility and feasibility that should suit corneal surgeons of all levels.
Key words: deep lamellar keratoplasty – double anterior chamber – penetrating keratoplasty – endothelium

Acta Ophthalmol. 2008: 86: 49–52
ª 2007 The Authors Journal compilation ª 2007 Acta Ophthalmol Scand

doi: 10.1111/j.1600-0420.2007.01004.x

Introduction
There are many reports of deep lamellar keratoplasty (DLK) carried out in patients with normal corneal endothelium (Archila 1984–1985; Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al.

2004; Wylegala et al. 2004; Shimmura et al. 2005). The advantages of DLK over penetrating keratoplasty include the elimination of endothelial rejection and the superior restoration of postoperative visual acuity (VA) (Shimazaki et al. 2002; Watson et al. 2004). Although penetrating keratoplasty results in good enough postoperative VA, endothelial rejection and

continuous endothelial cell loss are often encountered (Bourne et al. 1994; Lyons et al. 1994; Serdarevic et al. 1994; Krohn & Hovding 2005; Bertelmann et al. 2006). These phenomena do not occur with DLK. However, that DLK is a time-consuming procedure and that it occasionally involves the postoperative development of a double anterior chamber remain problems to be resolved (Archila 1984– 1985; Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). The original technique used in DLK involved using a donor cornea with its own endothelium (Archila 1984–1985). Recent reports have mainly described cases of donor corneas without endothelia (Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). The benefits of using a donor cornea without the endothelium in DLK include the convenience of using preserved corneas. Sugita & Kondo (1997) reported a study of 120 DLK cases. The donor corneas used in this study were full-thickness fresh corneas in 16 eyes, corneas with removed endothelium and Descemet’s membrane in 50 eyes, and corneas

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For the donor cornea. F ¼ female. Irvine.⁄ postoperative complications – Descemet’s membrane rupture. USA) was trephined from the endothelial side to a diameter of 7. 1998). Avellino corneal dystrophy (two eyes). At the end of surgery. Table 1. By contrast with recent studies. Corneal graft examination and VA measurements were carried out postoperatively at 1 week and at 1. 2 mg dexamethasone was injected into the subconjunctival area. Chau et al. M ¼ male.1% betamethasone) and antibiotics (ofloxacin) four times a day were prescribed. 50 . Age (years) 67 63 69 66 58 33 54 Intra. 7. corneal perforation (two eyes).75-mm diameter Hessburg)Barron disposable trephine (JEDMED Instrument Co.7. 6. HM ¼ hand movements.00 mm. In most cases.6 months). In addition.75 or 8.25. 3. double chamber – Follow-up (months) 86 72 72 82 70 113 89 Case 1 2 3 4 5 6 7 Disease Leukoma Leukoma Leukoma Leukoma Leukoma Gelatinous drop-like dystrophy Gelatinous drop-like dystrophy recurrence Gelatinous drop-like dystrophy recurrence Avellino corneal dystrophy recurrence Avellino corneal dystrophy recurrence Perforation Perforation Mucopolysaccharidosis Keratoconus Sex M F F F F M M Pre-DLK VA HM CF 20 ⁄ 630 20 ⁄ 100 20 ⁄ 100 20 ⁄ 1000 HM Post-DLK VA 20 ⁄ 40 20 ⁄ 200 20 ⁄ 50 20 ⁄ 50 20 ⁄ 25 20 ⁄ 30 20 ⁄ 40 Comments Macular degeneration (+) 8 9 10 11 12 13 14 30 68 30 19 65 21 26 F M F F M F M HM 20 ⁄ 63 20 ⁄ 2000 20 ⁄ 1000 20 ⁄ 2000 20 ⁄ 400 20 ⁄ 630 20 ⁄ 50 20 ⁄ 20 20 ⁄ 500 20 ⁄ 200 20 ⁄ 2000 20 ⁄ 100 20 ⁄ 30 72 75 55 88 87 90 74 Stromal opacity from herpes (+) Avellino recurrence (+) DLK ¼ deep lamellar keratoplasty. eight interrupted 10–0 nylon sutures were initially used to secure the corneal button in the recipient’s bed and were followed by a single continuous running suture with 16 bites. USA) before lamellar keratectomy was performed. Follow-up periods ranged from 55 to 113 months (mean 80. 9 and 12 months.5. The donor corneas used in our study were of full thickness and retained their own endothelia. the donor cornea will still be transparent because the graft’s endothelium is present and functioning. double chamber. double chamber Descemet’s membrane rupture. CF ¼ counting fingers. anterior chamber bleeding – – Descemet’s membrane rupture Descemet’s membrane rupture. They reported a mean best corrected visual acuity (BCVA) of 20 ⁄ 52 in 17 eyes of 15 patients at ‡ 6 months after DLK (Tsubota et al. only 16 interrupted sutures were needed. and keratoconus (one eye). Materials and Methods Fourteen eyes of 14 patients (six men and eight women.. we consider that using a donor cornea with its own endothelium in DLK is advantageous because it allows the surgeon the flexibility to change the planned DLK to penetrating keratoplasty if a complication occurs during surgery. a fresh sclerocorneal button which had been stored in OptisolÒ (Bausch & Lomb.4 mm in 54 eyes. Here we report the longterm results of our DLK cases using this technique.or 7. air was injected into the anterior chamber at the end of surgery.Acta Ophthalmologica 2008 cryolathed from the endothelial side to a thickness of approximately 0. 1992). When Descemet’s membrane was ruptured. Overviews of 14 cases of deep lamellar keratoplasty.5. VA ¼ visual acuity. In some cases. MO. mean age 47. and yearly thereafter. Therapeutic contact lenses were placed on some of the corneas. Tsubota et al. (1998) removed the endothelium and 30% of the stroma from the fresh donor corneas in their DLK operations. The recipient cornea was first trephined to three-quarters of its depth with a 7. even if a double anterior chamber is observed postoperatively. The study showed that postoperative transparency was achieved faster in eyes that received fresh corneas. They divided the recipient cornea into four quadrants to facilitate lamellar dissection and continued this procedure until Descemet’s membrane was exposed in the central area. The lamellar dissection was performed with a disposable blade and a spatula using the intrastromal air injection technique (Archila 1984–1985. 2. gelatinous drop-like corneal dystrophy (three eyes).8 ± 19. double chamber – – – – Descemet’s membrane rupture. double chamber Descemet’s membrane rupture. but similar results were observed later in eyes that received donor corneas which had been frozen and preserved (Sugita & Kondo 1997). Topical corticosteroid (0. CA. St Louis. The pre-DLK pathologies were: corneal leukoma (five eyes). Similarly.8 years [mean ± standard deviation]) were treated with DLK from June 1994 to October 1999 (Table 1).4 ± 13. corneal mucopolysaccharidosis (one eye).

if a graft without endothelium had been used. injecting air or SF6 gas into the anterior chamber in order to correct the double anterior chamber will occasionally be necessary. Shimmura et al. Sugita & Kondo 1997. respectively. this eye underwent DLK in December 1997. 1998. This case involved a 33-year-old man with gelatinous drop-like corneal dystrophy in both eyes. 2004. and there was almost no anterior chamber. In case 2. Coombes et al. when a double anterior chamber occurs in DLK using a donor cornea with endothelium. no double anterior chamber was observed after surgery. 2005). 2002. 1999. In recent years. 2004. 2004. In case 10. 2002. Rupture of Descemet’s membrane occurred in six eyes (43%) and was treated by injecting air into the anterior chamber at the end of surgery. At the last follow-up. Deep lamellar keratoplasty and keratoepithelioplasty (Turgeon et al. VA was 20 ⁄ 30. 2005) and 0–25% (Coombes et al. Sugita & Kondo 1997. the graft remained clear because its endothelium functioned properly. Dissection of the stroma was very difficult because of corneal mucopolysaccharidosis. However. air was injected on postoperative day 9 and the double anterior chamber disappeared on the following day. Preoperative VA in the right eye was 20 ⁄ 1000. 2005). Discussion Our study showed that. 2004. Rupture of Descemet’s membrane and the development of a double anterior chamber are reported to occur at rates of 15–50% (Sugita & Kondo 1997. 2001. Nevertheless. although Descemet’s membrane ruptured during DLK. angle closure and irreversible mydriasis. 1. Descemet’s membrane was exposed over a central area with a 5-mm diameter. even by experienced surgeons (Archila 1984–1985. 2005). The graft. Shimazaki et al. 2001. The photograph of these cysts taken by UBM has been presented previously by our group (Sato et al. Chau et al. 1992. At 38 and 113 months postsurgery. 2002. Melles et al. A double anterior chamber formed (Fig. Shimazaki et al. There were no episodes of endothelial rejection in any of the eyes. Melles et al. Watson et al. Tsubota et al. Photograph of persisting double anterior chamber in case 13 at 14 months after surgery. Watson et al. When DLK is performed using a donor cornea without the endothelium and a double anterior chamber develops. 1992. We previously reported a case where penetrating keratoplasty using the donor cornea with the endothelium 51 . 2002). As many DLK cases show. Coombes et al. cases 2. Descemet’s membrane ruptured and air was injected into the anterior chamber. Ultrasound biomicroscopy (UBM) showed that cysts under the iris had caused the narrowing of the 2004. DLK using the donor endothelium was of greater value than DLK without the endothelium. with its own endothelium. Coombes et al. Case reports Case 6 (Table 1) Fig. Wylegala et al. The host Descemet’s membrane is shown. Shimazaki et al. Without being ruptured. On the following day. Shimmura et al. air was observed between the iris and lens by slit-lamp examination. 2004. 1990) were performed in December 1995. Shimmura et al. the patient’s BCVA was 20 ⁄ 100 and the graft remained clear. A 21-year-old woman had opacified corneas caused by mucopolysaccharidosis in both eyes. Wylegala et al. Despite the existing double anterior chamber. rupture of Descemet’s membrane and the presence of a double anterior chamber represent complications that are frequently encountered. using gas injection to cancel the double anterior chamber promptly is not necessary and thus the undesirable complications caused by gas injection can be avoided. for the treatment of corneal opacities with normal corneal endothelium. By contrast. gas injection can cause pupillary blocks. Preoperative VA in the left eye was 20 ⁄ 400. As seen in case 13 in this study (Table 1). Case 13 (Table 1) anterior chamber. the graft in case 13 remained clear because its own endothelium was functioning normally. Based on these observations. 2002. A double anterior chamber occurred postoperatively in five eyes (36%. we decided that it would be too risky to inject additional air into the anterior chamber in this case. the graft with its own endothelium did not become oedematous. However. 1999. 1) and has persisted to date for 90 months after surgery. 7. Tsubota et al. Watson et al. it would have become oedematous when a double anterior chamber developed. 2001. 2001. 11 and 12). 12 and 13) and disappeared spontaneously within 1 week in three eyes (cases 7.Acta Ophthalmologica 2008 Results Best corrected VA improved in 13 of the 14 eyes (93%) (Table 1). 1998. The prepared corneal button was sutured on the recipient’s bed with eight interrupted sutures and a single continuous running 10–0 nylon suture with 16 bites. Shimazaki et al. DLK using the donor cornea without the endothelium has been commonly performed (Chau et al. despite the existing double anterior chamber. remained clear. Watson et al. 11. Shimmura et al.

Sugita & Kondo 1997). Am J Ophthalmol 118: 185–196. Rietveld FJR et al. Ophthalmology 101: 990–997. Slit-lamp examination indicated no opacity between the graft and the recipient’s cornea in any of our cases. Shimmura et al. Moreover. Moreover. Cornea 24: 178–181. Ramsay A. because this technique requires fewer tasks to be carried out and has a lower risk for adverse events occurring during the procedure. Serdarevic ON. Dart JK et al. Acta Ophthalmol Scand 84: 766–770. Recently. Shimomura Y et al. 1999. Omoto M et al. Shimazaki et al. Sugita J & Kondo J (1997): Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. excellent recovery of the patient’s VA was achieved because of the functioning donor endothelium. (2004): Comparison of deep lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus. Chau et al. 1999). Shimmura S. Kirkness CM et al. Sato S. 2005). Tarnawska D & Dobrowolski D (2004): Deep lamellar keratoplasty for various corneal lesions. 2004. 1992. Hodge DO & Nelson BA (1994): Corneal endothelium 5 years after transplantation. Bourne WM. Bertelmann E. anterior lamellar keratoplasty. this technique does not require any lathing (Chau et al. Ophthalmology 101: 1812–1817. Vajpayee RB.ac. Despite the presence of the host Descemet’s membrane. Acta Ophthalmol Scand 83: 746–750. Furthermore. Sugita & Kondo 1997. Roat MI et al. 2001. Although this procedure requires special devices. Nauheim RC. Accepted on June 6th. (1998): A new surgical technique for deep lamellar keratoplasty with single running suture adjustment. Tsubota et al. Eur J Ophthalmol 14: 467–472. In conclusion. Shimazaki J. Shimmura S. (2002): Randomized clinical trial of deep lamellar keratoplasty versus penetrating keratoplasty. even in cases of Descemet’s membrane rupture and a double anterior chamber. Monden Y et al. However. Tsubota K. Received on November 20th.Acta Ophthalmologica 2008 was the procedure initially planned to treat corneal stromal opacity in a patient with normal corneal endothelium (Higaki et al. Titiyal JS et al. (2005): Deep lamellar keratoplasty (DLKP) in keratoconus patients using viscoadaptive viscoelastics. (1999): Double anterior chamber deep lamellar keratoplasty: case report. As in case 13 here. Br J Ophthalmol 83: 327–333. Kirwan JF & Rostron CK (2001): Deep lamellar keratoplasty with lyophilised tissue in the management of keratoconus. Sheard CE et al. Another advantage of this technique is that it allows the surgeon to switch from the planned DLK procedure to a penetrating keratoplasty if any intraoperative complication such as Descemet’s membrane rupture covering more than 25% of cornea occurs. Wylegala E. Wylegala et al. Watanabe H et al. Arch Ophthalmol 108: 233–236. Am J Ophthalmol 134: 159– 165. Melles GRJ. Lyons CJ. Coombes et al. In addition. Cornea 18: 240–242. Melles et al. Br J Ophthalmol 85: 788–791. 2002. Ophthalmology 111: 1676–1682. 2006. (2006): Automated lamellar therapeutic keratoplasty (ALTK) in the treatment of anterior to mid-stromal corneal pathologies. it can be performed safely by less experienced or occasional corneal surgeons. 1992. thus reducing the tasks involved in the procedure.jp 52 . These results showed that our technique of using the graft with its endothelium can produce good results. although this did not arise in our cases. (1990): Indications for keratoepithelioplasty. Higaki S. the post-DLK restoration of VA in our cases was comparable with results in previous reports (Archila 1984–1985. (1994): Granular corneal dystrophy: visual results and pattern of recurrence after lamellar or penetrating keratoplasty. the risk of rejection of fresh tissue compared with freeze-dried or other non-viably stored tissue may become problematic. 1992. Cornea 3: 217– 218. Maeda N. Dilly SA. 2004. 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Renard GJ & Pouliquen Y (1994): Randomized clinical trial comparing astigmatism and visual rehabilitation after penetrating keratoplasty with and without intraoperative suture adjustment. Correspondence: Shiro Higaki Department of Ophthalmology Kinki University School of Medicine 377–2 Ohno-Higashi Osaka-Sayama Osaka 589-0014 Japan Tel: + 81 72 366 0221 Fax: + 81 72 368 2559 Email: higaki@ganka. Br J Ophthalmol 76: 646– 650. Ishioka M et al. Watson et al.med. DLK using a donor cornea with its own endothelium is beneficial and feasible. (2002): Multiple iridociliary cysts in patients with mucopolysaccharidoses. Watson SL. the results of automated lamellar therapeutic keratoplasty (ALTK) (Vajpayee et al. Vasudendra N. it has been thought to be safe and effective for diseases affecting the anterior to mid-stroma of the cornea. (1999): A new surgical technique for deep stromal. Turgeon PW. 1998. Chau GK. the procedure resulted in a double anterior chamber because the host Descemet’s membrane became inadvertently detached during the surgery. McCartney AC.kindai. Br J Ophthalmol 81: 184–188. 2006) have been reported.