Large-diameter deep anterior lamellar keratoplasty: A narrative review

Abstract

Deep anterior lamellar keratoplasty (DALK) involves the selective replacement of diseased corneal stroma while preserving healthy unaffected endothelium. While DALK has failed to gain widespread popularity, improved visual and refractive outcomes of large-diameter grafts, which patients directly perceive following suture removal, may represent a compelling reason to shift toward DALK. Since the unaffected host endothelium is retained, DALK offers the opportunity to use large-diameter grafts, which reliably achieves maximum visual potential without an increased risk of immune-mediated stromal rejection. In this narrative review, we evaluate the current evidence on large-diameter DALK including surgical technique and clinical outcomes.

Keywords: Anterior lamellar keratoplasty; big-bubble deep anterior lamellar keratoplasty; deep anterior lamellar keratoplasty; large-diameter keratoplasty; stromal disease.

Figure 1

Preoperative (a) and postoperative (b) photograph of a patient who underwent large-diameter deep anterior lamellar keratoplasty for herpetic scarring

Figure 2

Preoperative (a) and postoperative (b) photograph of a patient who underwent two-piece mushroom keratoplasty following an unsuccessful deep anterior lamellar keratoplasty for herpetic scarring

Figure 3

Anterior segment optical coherence tomography following large 9-mm diameter big-bubble deep anterior lamellar keratoplasty with limited stromal clearance of the optical zone showing the transition between the 6-mm central zone and the 9-mm outer zone with the residual recipient stroma. One day postoperatively, a peripheral stromal shoulder is clearly visible (a) but eventually disappears through spontaneous stromal thinning and remodeling of posterior corneal curvature 1 year (b), 2 years (c), and 4 years (d) after surgery