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Avoiding big bubble complications: outcomes of layer-by-layer deep anterior lamellar keratoplasty in children
  1. Uri Elbaz,
  2. Caitriona Kirwan,
  3. Carl Shen,
  4. Asim Ali
  1. Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Asim Ali, Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; asim.ali{at}


Background/aims To describe the visual and clinical outcomes of manual layer-by-layer deep anterior lamellar keratoplasty (DALK) in a paediatric population.

Methods The charts of all children who underwent DALK surgery between January 2007 and January 2015 were reviewed retrospectively. Data collected included preoperative and postoperative spectacle-corrected distance visual acuity (CDVA), intraoperative and postoperative complications including graft rejection and failure. Residual posterior lamellar thickness (RPLT) and endothelial cell density (ECD) were measured in eyes with follow-up longer than 6 months.

Results Fifty-one eyes of 42 patients were included in the study. The mean patient age at surgery was 11.2±5.2 years and the mean follow-up time was 36.5±23.7 months. The most common indications for surgery were mucopolysaccharidosis (29.4%) and keratoconus (23.5%). Nine eyes (17.6%) had intraoperative microperforation, none of which were converted to penetrating keratoplasty (PKP). Only one eye (2.0%) was converted to PKP. Five eyes (9.8%) had a stromal rejection episode of which one eye failed. Another four eyes (7.8%) experienced graft failure among which three eyes (75%) had infectious keratitis. Three of the five failed grafts had a successful repeat DALK. The average RPLT was 81.9±36.5μm. ECD was significantly lower in the operated eye compared with the normal eye (3096±333 cells/mm2 vs 3376±342 cells/mm2, n=11, P=0.003). The mean postoperative CDVA was 0.5±0.4 logarithm of the minimum angle of resolution (logMAR) reflecting a gain of 0.3 logMAR (P<0.001).

Conclusion Manual dissection DALK is a safe procedure in children with stromal opacities. Despite successful structural rehabilitation, functional recovery is still suboptimal mostly due to amblyopia.

  • cornea

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  • Contributors All authors contributed to the following: substantial contributions to the conception or design of the work or the acquisition, analysis or interpretation of data; drafting the work or revising it critically for important intellectual content; final approval of the version published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests None declared.

  • Patient consent Guardian consent obtained.

  • Ethics approval The Hospital for Sick Children REB committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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