Complications in deep anterior lamellar keratoplasty - A retrospective interventional analysis in a large series

Abstract

Purpose: To analyze the complications in patients managed with deep anterior lamellar keratoplasty (DALK) for diseases of the anterior corneal stroma.

Methods: This is a retrospective analysis of all the patients who underwent DALK in a tertiary care center in South India from 2010 to 2020. A total of 474 eyes in 373 patients were included in the study. Patients who underwent DALK for advanced keratoconus, keratoconus with Bowman's membrane scar, healed hydrops, macular corneal opacity, macular corneal dystrophy, granular corneal dystrophy, spheroidal degeneration, pellucid marginal degeneration, post-laser-assisted in situ keratomileusis ectasia, descematocele, post-collagen cross-linking aborted melt and dense scar, and post-radial keratotomy were included in the study. The patients were followed up for 17.2 +/- 9.2 months (1-9 years).

Results: Complications noted in the surgery were intra-operatively Descemet's membrane perforation in 31 eyes (6.54%), post-operatively secondary glaucoma in 16 eyes (3.37%), cataract in seven eyes (1.47%), suture-related complications in five eyes (1.05%), graft rejection in three eyes (0.63%), traumatic dehiscence in two eyes (0.42%), filamentary keratitis in two eyes (0.42%), interface infiltrate in one eye (0.21%), and recurrence of disease in four eyes (7.14%) out of 57 eyes with corneal dystrophy.

Conclusion: DALK as an alternative to penetrating keratoplasty for anterior corneal stromal diseases. It has become an automatic choice for diseases of the anterior cornea requiring keratoplasty. Complications can occur at any stage of surgery; however, if identified and managed early, they can result in optimal outcome.

Keywords: Deep anterior lamellar keratoplasty; Descemet's membrane perforation; double anterior chamber; graft rejection; interface infectious keratitis.

Figure 1

Intra-operative complications: (a) Outcome after macro-perforation of Descemet’s membrane, (b) outcome after micro-perforation of Descemet’s membrane, (c) pre-operative anterior segment optical coherence tomography picture of healed acute hydrops, and (d) post-operative picture of the same patient showing healed Descemet’s perforation

Figure 2

Slit-lamp photograph of post-operative complications showing (a) double anterior chamber, (b) post-operative picture of the same patient after management, (c) raised IOP with graft edema, (d) therapeutic DALK performed in descematocele with minimal central scarring, (e) interface infectious keratitis, (f) recurrence of granular corneal dystrophy, (g) Descemet’s membrane detachment after suture removal, (h) same patient after corrective suturing of detached Descemet’s membrane, and (i) stromal graft rejection

Figure 3

Astigmatism correction: (a) Slit-lamp photograph of a patient showing tight sutures at the corresponding steep axis, (b) topography of the same patient showing high astigmatism, (c) slit-lamp photo after the removal of the suture, and (d) topography showing reduction in astigmatism