Outcome of deep anterior lamellar keratoplasty patients with intraoperative Descemet's membrane perforation: A retrospective cross-sectional study

Abstract

Purpose: To evaluate functional and anatomical outcome in patients undergoing deep anterior lamellar keratoplasty (DALK) with intraoperative Descemet's membrane (DM) perforation (macro and micro).

Methods: A retrospective cross sectional study (January 2009 to December 2015) of sixteen eyes of sixteen patients which included nine patients of advanced keratoconus (KC), two patients with paracentral DM scarring post hydrops, KC with Bowman's membrane scarring, macular corneal dystrophy and one patient of advanced Pellucid Marginal Degeneration (PMD). All underwent DALK with intraoperative DM perforation. Big bubble technique was attempted in all except in the two patients with post hydrops DM scar. Preoperative and postoperative best corrected visual acuity (BCVA), astigmatism and endothelial count (EC) were compared.

Results: Postoperative BCVA and astigmatism were found to be better and statistically significant ('p value' 0.00 and 0.003 respectively). BCVA preoperative and postoperative was 1.07± 0.3 and 0.28 ± 0.09 in LogMAR respectively and astigmatism pre and postoperative 4.14 ± 1.5 D and 2.7 ± 0.97 D respectively. Percentage decrease in EC at sixth postoperative week was 7.48% and at sixth month and 1 year postoperative was 15.1%. Two patients developed postoperative double anterior chamber and two patients developed pupillary block glaucoma and all were successfully managed.

Conclusion: Not all patients of intraoperative DM perforation (including macro perforation) needs to be converted to penetrating keratoplasty. DALK can be successfully done if the perforation is identified early and managed adequately. This is the only known study which has shown a large series of successful DALK even with macro perforations.

Keywords: Deep anterior lamellar keratoplasty; Descemet's membrane perforation; double anterior chamber; macro perforation; micro perforation.

Figure 1

Patient with double anterior chamber

Figure 2

Patient after resolving of double chamber

Figure 3

Patients with macroperforation during DALK and good postoperative outcome, at the end of 1 year

Figure 4

Patients with macroperforation during DALK and good postoperative outcome, at the end of 1 year

Figure 5

Microperforation during DALK and postoperative outcome, at 1 year

Figure 6

Microperforation during DALK and postoperative outcome, at 1 year

Figure 7

Specular image of patient preoperative

Figure 8

Specular image of the same patient at postoperative 6 weeks

Graph 1

Decrease in endothelial cell (EC) count over different periods of time postoperatively. X-axis represents time period of follow-up in our study. (1 = preoperative period, 2 = 6 weeks postoperative period, 3 = 6 months postoperative period, and 4 = 1 year postoperative period). Y-axis shows the estimated marginal means in cells/mm²