Original article
Randomized clinical trial of deep lamellar keratoplasty vs penetrating keratoplasty1

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Abstract

PURPOSE: To prospectively compare the safety and efficacy of deep lamellar keratoplasty (DLKP) and penetrating keratoplasty (PKP).

DESIGN: Prospective, randomized clinical trial.

METHODS: Consecutive 26 eyes of 24 patients who had stromal opacity without endothelial abnormalities were randomly assigned to either PKP or DLKP. Best-corrected visual acuity (BCVA), contrast visual acuity, glare test, intraocular pressure, corneal topography, endothelial density, and pachymetry were measured before and after surgery.

RESULTS: Two eyes in the DLKP had rupture of the Descemet membrane and one of the eyes developed endothelial decompensation. One eye in the PKP group showed decreases in vision due to secondary glaucoma. None of the eyes developed immunologic rejection. The PKP group showed a tendency of faster recovery in BCVA than the DLKP group, but the difference was not statistically significant. Contrast visual acuity, glare test, and corneal topography did not show significant differences between the two groups. The intraocular pressure was significantly higher at 12 months in the PKP group (P = .004), but not in the DLKP group (P = .41) compared with preoperative values. While the PKP group showed progressive decrease in endothelial density over 24 months, this was not observed in the DLKP group after surgery. Difference in endothelial density at 24 months reached statistical significance (P = .04).

CONCLUSIONS: We found that DLKP was superior to PKP in its safety such as continuous decreases of endothelium or increases in intraocular pressure. However, endothelial damage can also occur in DLKP, especially in cases of intraoperative Descemet membrane rupture. With the development of easier surgical techniques, DLKP may be a first choice of keratoplasty in most eyes without endothelial abnormalities.

Section snippets

Design

The study was conducted in a prospective, randomized fashion. Patients were randomly assigned based on a surgical chart number (patients with even numbers were assigned to PKP and with odd numbers to DLKP) to receive either PKP (PKP group) or DLKP (DLKP group). All donor corneas were transported from eye banks in the United States, and met the criteria of the Eye Bank Association of America for donor quality.

Methods

Patients requiring keratoplasty for corneal stromal opacity without endothelial disease were enrolled between December 1996 and November 1998 in the Department of Ophthalmology, Tokyo Dental College. All patients received explanation about the purpose of the study as well as advantages and disadvantages of both PKP and DLKP. Informed consent was obtained from all patients who agreed to participate in the study. Eyes that required additional surgery such as cataract extraction simultaneously

Graft clarity and complications

In the DLKP group, the Descemet membrane perforated during surgery in two eyes, leading to detachment of the Descemet membrane postoperatively. One eye with post-herpetic stromal opacity received injection of a mixture of air and sulfurhexafluoride (SF6) in the anterior chamber without success. The Descemet membrane was not repositioned and the eye eventually developed endothelial decompensation. The patient then had PKP 17 weeks after surgery and the graft remains clear with a CVA of 20/15.

Discussion

Deep lamellar keratoplasty was first reported by Archila and associates in 1985.7 By replacing diseased tissue with healthy donor cornea, improvement in visual acuity can be obtained, while the risk of endothelial rejection or intraocular complication can be lowered. In addition, more donor corneas can be used in DLKP since the procedure does not require a healthy donor endothelium. This is an important issue in countries where donor corneas are lacking. There have been a number of reports

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1

InternetAdvance publication at ajo.com April 19, 2002.

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