Elsevier

Ophthalmology

Volume 118, Issue 2, February 2011, Pages 294-301
Ophthalmology

Original article
Split Cornea Transplantation for 2 Recipients: A New Strategy to Reduce Corneal Tissue Cost and Shortage

https://doi.org/10.1016/j.ophtha.2010.05.025Get rights and content

Purpose

To evaluate the feasibility of using a single donor cornea for 2 recipients by combining deep anterior lamellar keratoplasty (DALK) and Descemet's membrane endothelial keratoplasty (DMEK) surgeries on the same day.

Design

Single-center, nonrandomized, prospective, interventional case series.

Participants

Twelve consecutive donor corneas were scheduled for split cornea transplantation combining DALK for a keratoconus patient and DMEK for a Fuchs' endothelial dystrophy patient on the same surgery day.

Methods

First, a big-bubble DALK procedure was performed for the keratoconus eye. When bare Descemet's membrane was prepared successfully requiring no conversion to penetrating keratoplasty (PK), then during surgery the donor, endothelium–Descemet's membrane layer was removed and stored for subsequent DMEK in a second patient, and the remaining anterior lamella of the donor cornea was used to complete the DALK surgery. Afterward, a DMEK procedure was performed on the second patient with Fuchs' endothelial dystrophy, grafting the stored endothelium–Descemet's membrane layer of the original donor button.

Main Outcome Measures

Success of using a single donor cornea for 2 recipient eyes, best spectacle-corrected visual acuity (BSCVA), and complication rates within 6 months follow-up.

Results

A single donor cornea could be used for 2 recipients in 10 of 12 donor buttons (83%). In 2 cases (17%), the DALK procedure had to be converted to PK requiring a full-thickness corneal graft. Therefore, 10 donor corneas (45%) could be saved. Six months after surgery, mean BSCVA was 20/35 (range, 20/50–20/25) in 10 eyes that underwent successful DALK, 20/50 (range, 20/63–20/40) in 2 eyes that underwent conversion from DALK to PK, and 20/31 (range, 20/50–20/16) in 10 eyes that underwent DMEK. Postoperative complications after DALK included Descemet's folds in 3 eyes (30%) and epitheliopathy in 2 eyes (20%). After DMEK, partial graft detachment occurred in 5 eyes (50%) and was managed successfully with intracameral air reinjection. All corneas remained clear up to 6 months after surgery.

Conclusions

Split use of donor corneal tissue for combined DALK and DMEK procedures in 2 recipients on the same surgery day is a promising strategy to reduce donor shortage and cost in corneal transplantation surgery in the future.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Section snippets

Patients and Methods

Between June and September 2009, 12 consecutive donor corneas were planned for split cornea transplantation at the Department of Ophthalmology, University Eye Hospital, Friedrich-Alexander University Erlangen-Nürnberg, Germany. Of 289 patients waiting for a keratoplasty, 1 consecutive patient with keratoconus suitable for a DALK procedure and 1 consecutive patient with Fuchs' endothelial dystrophy suitable for a DMEK procedure were scheduled for the same surgery day. This was done for a total

Deep Anterior Lamellar Keratoplasty

Twelve keratoconus eyes of 4 women and 8 men (mean age±SD at the time of surgery, 41.5±14.5 years; range, 24–66 years) were scheduled for DALK (Table 1, available at http://aaojournal.org). The mean preoperative BSCVA was 20/131 (range, 20/200–20/63), the spherical equivalent was –3.5±2.7 diopters (D; range, –10.5 to 0.0 D), and the refractive astigmatism was 2.6±2.3 D (range, 0.0–8.5 D). The preoperative central corneal thickness averaged 411±60 μm (range, 326–498 μm), and the endothelial cell

Discussion

Both DALK using the big-bubble technique and DMEK are relatively new surgical techniques. Both lamellar approaches of corneal transplantation theoretically come close to an ideal surgical solution for the respective diseases they are intended to cure. In corneal diseases affecting solely the anterior stroma and not the endothelium–Descemet's membrane layer, such as keratoconus, only the anterior part of the cornea (including epithelium, its basement membrane, Bowman's layer, and stroma) is

References (54)

  • M.A. Terry et al.

    Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure

    Ophthalmology

    (2009)
  • M.A. Terry et al.

    A prospective study of endothelial cell loss during the 2 years after deep lamellar endothelial keratoplasty

    Ophthalmology

    (2007)
  • J.T. Lie et al.

    Donor tissue preparation for Descemet membrane endothelial keratoplasty

    J Cataract Refract Surg

    (2008)
  • L. Ham et al.

    Endothelial cell density after Descemet membrane endothelial keratoplasty: 1- to 2-year follow-up

    Am J Ophthalmol

    (2009)
  • M.O. Price et al.

    Descemet's membrane endothelial keratoplasty: prospective multicenter study of visual and refractive outcomes and endothelial survival

    Ophthalmology

    (2009)
  • D. Cintorino et al.

    In situ split liver transplantation for adult and pediatric recipients: an answer to organ shortage

    Transplant Proc

    (2006)
  • T.M. De By

    Shortage in the face of plenty: improving the allocation of corneas for transplantation

    Dev Ophthalmol

    (2003)
  • B. Seitz et al.

    The penetrating keratoplasty: a 100-year success story [in German]

    Ophthalmologe

    (2005)
  • S. Das et al.

    Long-term refractive and visual outcome after penetrating keratoplasty only versus the triple procedure in Fuchs' dystrophy

    Graefes Arch Clin Exp Ophthalmol

    (2006)
  • G.R. Melles et al.

    A new surgical technique for deep stromal, anterior lamellar keratoplasty

    Br J Ophthalmol

    (1999)
  • M. Anwar et al.

    Deep lamellar keratoplasty: surgical techniques for anterior lamellar keratoplasty with and without baring of Descemet's membrane

    Cornea

    (2002)
  • J.L. Alio et al.

    New techniques in lamellar keratoplasty

    Curr Opin Ophthalmol

    (2002)
  • A. Parthasarathy et al.

    Simplified technique for deep lamellar keratoplasty [letter]

    Cornea

    (2008)
  • A. Parthasarathy et al.

    Use of a “small-bubble technique” to increase the success of Anwar's “big-bubble technique” for deep lamellar keratoplasty with complete baring of Descemet's membrane

    Br J Ophthalmol

    (2007)
  • L. Fontana et al.

    Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus

    Am J Ophthalmol

    (2007)
  • R. Fogla et al.

    Results of deep lamellar keratoplasty using the big-bubble technique in patients with keratoconus

    Am J Ophthalmol

    (2006)
  • I. Bahar et al.

    Comparison of three different techniques of corneal transplantation for keratoconus

    Am J Ophthalmol

    (2008)
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      Citation Excerpt :

      The existing donor supply can be extended by dividing a single donor cornea among multiple recipients, for which DMEK is particularly well suited. One way of splitting the tissue is to use the corneal endothelium for DMEK and the stromal tissue for deep anterior lamellar keratoplasty (Heindl et al., 2011). However, the demand for corneal endothelial tissue substantially exceeds the demand for corneal stromal tissue (Eye Bank Association of America, 2020).

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    Manuscript no. 2010-135.

    Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

    Supported by the Interdisciplinary Center for Clinical Research (IZKF) Erlangen (A9), Erlangen, Germany.

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