Deep anterior lamellar keratoplasty: indications, surgical techniques and complications

Abstract

The concept of lamellar keratoplasty (LK) is not new. However, it had been abandoned and largely replaced by the time-honored technique of penetrating keratoplasty (PK) because LK is technically demanding, time consuming and gives suboptimal visual outcomes due to interface irregularity arising from manual lamellar dissection. Recent improvements in surgical instruments and introduction of new techniques of maximum depth of corneal dissection as well as inherent advantages such as preservation of globe integrity and elimination of endothelial graft rejection have resulted in a re-introduction of LK as an acceptable alternative to conventional PK. This review article describes the indications, different techniques, clinical outcomes and complications of deep anterior LK.

Keywords: Anwar's Big-bubble Technique; Deep Anterior Lamellar Keratoplasty; Lamellar Keratoplasty; Melles'Technique; Penetrating Keratoplasty.

Figure 1

(a) Air injection deep into the stroma with a bevel-down 27-G needle; (b) Round big-bubble formation passing the trephination borders; (c) Formed big-bubble; (d) Exposed Descemet's membrane after removal of the corneal stroma; (e) Removal of donor Descemet's membrane; (f) Conclusion of deep anterior lamellar keratoplasty with the combined suturing technique

Figure 2

Pseudo-anterior chamber formation due to microperforation of the Descemet's membrane

Figure 3

Iris stromal atrophy following managed post-operative pupillary block

Figure 4

Interface wrinkling following deep anterior lamellar keratoplasty

Figure 5

Vascularization of the interface with protein extravasations and opacification

Figure 6

Suture-induced reaction, cheese-wiring and loose sutures after deep anterior lamellar keratoplasty