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Much froth over bubbles
  1. Harminder S Dua1,
  2. Dalia G Said1,2
  1. 1Queens Medical Centre, University of Nottingham, England
  2. 2Research Institute of Ophthalmology, Cairo, Egypt
  1. Correspondence to Professor Harminder S Dua, Division of Ophthalmology and Visual Sciences, B Floor, Eye ENT Centre, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK; harminder.dua{at}

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Modern lamellar corneal grafting has done to penetrating keratoplasty what phacoemulsification did to extracapsular cataract extraction a few decades ago. Although, in a global context, both extracapsular cataract extraction and penetrating keratoplasty are probably more often performed than their modern counterparts, an irreversible change for better and for good has occurred. The concept of replacing only the diseased ‘layer(s)’ of the cornea, instead of replacing the whole (full thickness) cornea is not new. The earliest attempts at corneal grafting were indeed lamellar.1 Modern instrumentation and technology, in particular the operating microscope, have enabled surgeons to revisit the old concept and succeed where their predecessors had failed. When the stroma is affected with ectasia, scars or dystrophies such as granular or lattice, but the endothelium is normal, it makes sense to leave the recipient Descemet's membrane and endothelium behind. This considerably reduces the risk of immune rejection and graft failure. A collective term used to describe this approach is deep anterior lamellar keratoplasty (DALK).2 3 On the other hand, when the endothelium is affected, as in endothelial dystrophies, in particular Fuch's dystrophy and pseudophakic bullous keratopathy, it makes sense to replace only the endothelium while retaining the recipient's stroma and epithelium. This not only maintains corneal integrity and curvature, conferring a huge advantage, but for reasons not yet fully understood, also reduces the incidence of endothelial rejection.4 Endothelial keratoplasty has evolved rapidly over the last decade leaving in its wake a trail of new and at times confusing terminology. Descemet's lamellar endothelial keratoplasty,5 posterior lamellar keratoplasty,6 Descemet's stripping endothelial keratoplasty (DSEK),7 Descemet's stripping automated endothelial keratoplasty,8 Descemet's membrane endothelial keratoplasty (DMEK)9 and Descemet's membrane automated keratoplasty10 all refer to approaches towards the same objective and are more representative of the phases through …

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  • Competing interests None.

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

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