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Evaluation of the risk factors associated with conversion of intended deep anterior lamellar keratoplasty to penetrating keratoplasty
  1. James Myerscough1,2,
  2. Asaf Friehmann3,
  3. Cristina Bovone2,4,
  4. Michael Mimouni5,
  5. Massimo Busin2,4
  1. 1 Department of Ophthalmology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
  2. 2 Ophthalmology, Villa Igea Hospital, Forli, Italy
  3. 3 Department of Ophthalmology, Meir Medical Center, Kfar Saba, Israel
  4. 4 Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
  5. 5 Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
  1. Correspondence to Dr Massimo Busin, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara 44121, Italy; mbusin{at}


Background/aims To identify and evaluate risk factors associated with the need to convert intended deep anterior lamellar keratoplasty (DALK) to penetrating keratoplasty (PK).

Methods Retrospective institutional cohort study including all consecutive eyes undergoing intended DALK between May 2015 and October 2018 at ‘Villa Igea’ Hospital (Forli, Italy). The indications for surgery were categorised as (1) keratoconus without scarring; (2) keratoconus with scarring; (3) non-keratoconus without scarring; and (4) non-keratoconus with scarring. Multivariate binary logistic regression analysis was performed, introducing, as independent variables, those that reached a significance level of less than 0.05 in univariate analysis. The main outcome measure was whether or not conversion to a PK occurred.

Results 705 eyes were included, with conversion to PK occurring in 16.2% (n=114) of cases. The factors that remained significant in multivariate analysis were corneal scarring (OR=3.52, p<0.001), manual dissection (OR=42.66, p<0.001), type 2 bubble (OR=90.65, p<0.001) and surgeon inexperience (OR=10.86, p<0.001). A receiver operating characteristic (ROC) curve based on the factors significant in the multivariate binary logistic regression analysis achieved a sensitivity of 89.5% (95% CI 82.3% to 94.4%) and a specificity of 80.2% (95% CI 76.8% to 83.3%) with an area under the ROC curve of 0.91 (95% CI 0.88 to 0.93) (p<0.001)

Conclusion Occurrence of a type 2 bubble, the need for manual dissection, the presence of scarring and surgeon inexperience are independent risk factors for the need to convert intended DALK to PK. Correct identification and management of the type of bubble achieved during pneumatic dissection is instrumental in minimising the rate of conversion to PK.

  • Cornea

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MB received (2006–2016) reimbursement of travel expenses and royalties from Moria (Antony, France).

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the local ethics committee of ‘Villa Igea’ Hospital (Forlì, Italy).

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

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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