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Stromal peeling for deep anterior lamellar keratoplasty in post-penetrating keratoplasty eyes
  1. Cristina Bovone1,2,3,
  2. Yoav Nahum4,5,
  3. Vincenzo Scorcia6,
  4. Giuseppe Giannaccare6,
  5. Rossella Spena1,2,3,
  6. James Myerscough2,3,7,
  7. Angeli Christy Yu1,2,3,
  8. Massimo Busin1,2,3
  1. 1Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
  2. 2Department of Ophthalmology, Ospedali Privati Forlì “Villa Igea”, Forlì, Italy
  3. 3Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
  4. 4Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel
  5. 5Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
  6. 6Department of Ophthalmology, Magna Graecia University of Catanzaro, Catanzaro, Italy
  7. 7Department of Ophthalmology, Southend University Hospital, Southend, United Kingdom
  1. Correspondence to Dr Massimo Busin, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara 47122, Italy; mbusin{at}


Background/aims To evaluate the clinical outcomes of deep anterior lamellar keratoplasty performed by stromal peeling in eyes that have previously undergone penetrating keratoplasty (PK) for keratoconus.

Methods Standardised stromal exchange included (1) 9 mm trephination of the recipient bed outside the old PK wound, (2) creation of a partial anterior corneal flap through lamellar dissection across the PK wound, (3) opening the stromal component of the old PK wound using blunt-tipped Vannas scissors until a plane of separation is reached, (4) severing the attachment of the PK surgical scar from the recipient host, (5) peeling the stroma of the PK graft from the underlying tissue and (6) suturing the donor anterior corneal lamella prepared by microkeratome dissection (450 µm depth, 9 mm diameter). Main outcome measures were success rate, best spectacle-corrected visual acuity (BSCVA) and endothelial cell loss (ECL).

Results Of 21 post-PK eyes, stromal exchange succeeded in all but three cases, which were converted to a two-piece mushroom PK. After complete suture removal, mean BSCVA significantly improved from 0.95±0.39 logMAR preoperatively to 0.23±0.17 logMAR (p<0.001). Mean ECL was 5.4±23.2%. Double anterior chamber formation occurred in eight cases (44%), which all resolved after a single re-bubbling.

Conclusion In post-PK eyes, stromal exchange can be performed by means of simple peeling without deep anterior lamellar dissection of the previous PK graft. Large-diameter (9 mm) repeat keratoplasty through stromal peeling yields excellent visual outcomes and minimal ECL. Double anterior chamber formation may complicate the postoperative course, but prompt intervention allows successful management.

  • cornea
  • treatment surgery

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  • Contributors Concept and design of the study: CB, VS and MB. Data acquisition: YN, GG, RS and JM. Data analysis/interpretation: JM, ACY and MB. Drafting the manuscript: CB, YN, VS, GG, RS and JM. Critical revision of manuscript: ACY and MB. Statistical analysis: YN and ACY. Final approval: CB, YN, VS, GG, RS, JM, ACY and MB.

  • 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 None declared.

  • Patient consent for publication Not required.

  • Ethics approval Approval was obtained from the Comitato Etico of Ospedali Privati Forlì, Forlì, Italy (CEOPF2013-003).

  • 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 online supplemental information.

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