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Visual acuity outcomes after deep anterior lamellar keratoplasty: a case-control study
  1. D T H Tan1,2,3,
  2. A Anshu1,2,
  3. A Parthasarathy1,2,
  4. H M Htoon1,2
  1. 1Singapore National Eye Centre, Singapore, Singapore
  2. 2Singapore Eye Research Institute, Singapore, Singapore
  3. 3Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  1. Correspondence to Professor Donald Tan, Singapore National Eye Centre, 11, Third Hospital Avenue, Singapore 168751, Singapore; snecdt{at}


Aim To compare visual outcomes between deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK). Secondarily to compare refractive outcomes, complications and graft survival between the three cohorts.

Methods Retrospective case-control study evaluating visual acuity outcomes (VA) following DALK with complete Descemet's baring (DALKa) (modified Anwar big bubble technique—51 eyes), pre-descemetic anterior lamellar keratoplasty (DALKm) (manual technique—52 eyes) and PK (103 eyes) with mean follow-up of 13.6, 19.3 and 18.6 months, respectively.

Results The common indications for surgery were corneal scars (36.4%), keratoconus (28.6%) and corneal dystrophies (13.6%). A best-corrected VA of 6/7.5 or better was achieved in 19.4% (PK), 21.6% (DALKm) and 38.5% (DALKa) of cases (p=0.02), and eyes that underwent DALKa had significantly better visual outcomes than PK (p=0.03). Complications following PK were glaucoma (15%), endothelial rejection (12%) and epithelial problems (11%); in the lamellar group, glaucoma (9%), epithelial problems (5%) and Descemet's detachment (3%) were more common. The 2-year estimated probability of graft survival was 90% for PK, 98% for DALKm and 100.0% for DALKa (p=0.35).

Conclusions Lamellar keratoplasty with complete baring of the Descemet's membrane (DALKa) gave significantly better visual outcomes compared to PK or pre-descemetic ALK and should be the preferred from of corneal replacement in corneal disorders with healthy endothelium.

  • Anterior lamellar keratoplasty
  • big bubble technique
  • keratoconus
  • Descemet's membrane
  • penetrating keratoplasty
  • cornea

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Institutional Review Board of the Singapore Eye Research Institute.

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

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