Effect of hinged lamellar keratotomy on postkeratoplasty eyes

doi:10.1016/S0161-6420(01)00702-3

Ophthalmology

Volume 108, Issue 10, October 2001, Pages 1845-1851

Presented in part at the American Academy of Ophthalmology annual meeting, Dallas, Texas, October 2000.

https://doi.org/10.1016/S0161-6420(01)00702-3 Get rights and content

Abstract

Purpose:

To evaluate the effect of a hinged lamellar keratotomy on refraction, vision, and corneal topography of postkeratoplasty eyes with high-degree astigmatism.

Design:

Noncomparative, interventional case series.

Participants:

A hinged lamellar keratotomy was performed on nine eyes of nine patients at least 9 months after penetrating keratoplasty and with high-degree astigmatism. All patients were spectacle and contact lens intolerant.

Intervention:

A superiorly hinged lamellar keratotomy (corneal flap), 160 μm in thickness and 9 mm in diameter, was created on all eyes included in this study. Each patient was examined 1 day, 1 month, and 3 months after surgery.

Main Outcome Measures:

Uncorrected visual acuity, best spectacle-corrected visual acuity, refraction, computerized analysis of corneal topography.

Results:

At each postoperative examination time, there was a significant reduction in both average spherical equivalent (P < 0.05) and average absolute value of astigmatism (P < 0.01) over mean preoperative values. The major changes were seen as early as 1 day after surgery, but both progression and regression of the effect were documented at later postoperative examinations. In all patients best spectacle-corrected acuity was maintained or improved after the procedure. Postoperatively, four patients could be successfully corrected either with spectacles (n = 2) or with gas-permeable contact lenses (n = 2). There were no surgical flap or corneal graft complications.

Conclusions:

Hinged lamellar keratotomy improves vision and refraction of postkeratoplasty eyes with high-degree astigmatism. In some cases it may be so effective as to make planned excimer laser treatment unnecessary.

Section snippets

Patients and methods

All patients seen between June and December 1999 with postkeratoplasty refractive anisometropia greater than 3 D and high-degree astigmatism (>4 D) were included in a nonmasked, noncontrolled clinical trial aimed at assessing the effect of a hinged lamellar keratotomy on these eyes. All patients were at least 1 year after PK surgery and 3 months after suture removal. They had failed to tolerate contact lenses of any type and were therefore functioning monocularly with the fellow eye. A hinged

Results

Nine eyes of nine patients were included in this study. Five were male and four female. Their ages ranged from 31 to 74 (average, 59.1) years. Five patients had undergone PK surgery for keratoconus, three for bullous keratopathy, and one for a corneal dystrophy. Intaocular lens exchange had been combined with PK surgery in two patients with bullous keratopathy. Relaxing incisions inside the graft had been performed in one keratoconus patient several months after suture removal.

An average of 22

Refraction

When entering the study, all eyes had a myopic refraction with an average spherical equivalent of −5.40 D ± 1.69 D. This value decreased to −4.54 D ± 1.76 D at 1 day, −4.23 D ± 1.76 D at 1 month, and −4.37 D ± 1.72 D at 3 months after performing the hinged lamellar keratotomy.

Except for one patient, who experienced an increase of 0.50 D, a reduction in myopic spherical equivalent was seen in all patients at all postoperative examination times. The reduction was significant (P < 0.05) at all

Visual acuity

Preoperative uncorrected visual acuity (UCVA) was 20/400 or lower in all cases. No patient experienced a postoperative reduction of UCVA. On the first day after surgery, UCVA was 20/200 in three cases, 20/400 in two cases, and counting fingers in the remaining four cases. One month postoperatively, UCVA was 20/100 in two patients, 20/200 in two patients, 20/400 in one patient, and counting fingers in the remaining four patients. Three months after surgery, no further substantial changes of UCVA

Corneal topography

Corneal topographic patterns closely reflect the refractive changes measured after surgery. Figure 4 A, B illustrates the reduction in both spherical equivalent and astigmatism occurring as early as 1 day after the hinged lamellar keratotomy had been performed in a patient with approximately 5 D of astigmatism. In this patient, although minor topographic variations were seen at later postoperative times (Fig 4C, D), no substantial changes in refraction were recorded.

Figure 5 documents a

Discussion

Anisometropia with or without high-degree astigmatism is a relatively frequent postoperative complication of PK surgery.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 In the past, incisional surgery has shown fair capability of correcting postkeratoplasty astigmatism but has failed to prove effective for spherical refractive errors.18, 19, 20, 21, 22, 23 More recently, with the development of excimer lasers, surgeons hoped to consistently improve the refractive results obtainable on postkeratoplasty eyes.

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Cited by (36)

Post-penetrating keratoplasty astigmatism
2022, Survey of Ophthalmology
Citation Excerpt :
Creation and healing of a hinged LASIK flap itself can cause a significant change in the corneal shape and astigmatism. This is attributed to the release of uneven tension following wound healing in a post-PKP cornea.36,287,156 A two-step technique of creating a flap first and then relifting the flap after 4–6 weeks to perform excimer ablation has therefore been advocated.
Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.
Combined intrastromal astigmatic keratotomy and laser in situ keratomileusis flap followed by photoablation to correct post-penetrating keratoplasty ametropia and high astigmatism: One-year follow-up
2015, Journal of Cataract and Refractive Surgery
Citation Excerpt :
It is a safe, effective, and rapid method to treat post-PKP astigmatism that cannot be corrected with spectacles or contact lenses.13 In our study, we combined LASIK flap creation with intrastromal AK because the LASIK flap has a significant effect on the astigmatism in post-keratoplasty eyes.17,18 The lamellar cut altered irregular forces generated at the graft–host interface caused by wound shape and wound healing after suture removal.
To evaluate a new technique combining intrastromal astigmatic keratotomy (AK) with a laser in situ keratomileusis (LASIK) flap followed by excimer laser photoablation to correct post–penetrating keratoplasty (PKP) high astigmatism and ametropia.
Kasr El Aini Hospital, Cairo University, Cairo, Egypt.
Prospective interventional uncontrolled case series.
Patients with post-PKP high astigmatism and ametropia had paired intrastromal AK with LASIK flap using the M2 microkeratome followed 2 to 3 months later by excimer laser photoablation. The main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), mean refractive spherical equivalent (SE), and mean cylinder after each step and at the 1-year follow-up.
The study comprised 20 eyes (20 patients). All parameters were significantly improved in all patients by the last follow-up visit. The mean UDVA improved from 1.07 logMAR ± 0.2 (SD) preoperatively to 0.23 ± 0.18 logMAR (P < .001), the mean CDVA improved from 0.79 ± 0.18 logMAR to 0.12 ± 0.12 logMAR (P < .001), the mean refractive SE improved from −5.04 ± 2.62 diopters (D) to −1.47 ± 1.32 D (P = .001), and the mean cylinder reduced from −5.39 ± 0.98 D to −1.05 ± 0.71 D (P < .001). The mean correction index was 0.84 ± 0.10, and the mean flattening index was 0.83 ± 0.10. Thirty-five percent of cases developed microperforations, and 15% developed epithelial ingrowth.
This combined approach allowed for the correction of high astigmatism and ametropia following PKP; however, epithelial ingrowth requiring intervention is a complication to be considered.
No author has a financial or proprietary interest in any material or method mentioned.
Laser in situ keratomileusis after deep anterior lamellar keratoplasty
2013, Journal of Cataract and Refractive Surgery
Laser in situ keratomileusis to manage refractive errors after deep anterior lamellar keratoplasty
2012, Journal of Cataract and Refractive Surgery
To analyze the visual and refractive outcomes of laser in situ keratomileusis (LASIK) after deep anterior lamellar keratoplasty (DALK) for keratoconus.
Haydarpasa Numune Education and Research Hospital, Ophthalmology Clinic, Istanbul, Turkey.
Cohort study.
Patients with compound myopic astigmatism after DALK and a spherical equivalent (SE) between −2.50 diopters (D) and −8.00 D had LASIK as a single-step procedure, correcting the manifest refraction error. The visual and refractive results at 1 month, 3 months, and the last follow-up were compared with preoperative values.
The mean follow-up was 11.17 months ± 3.61 (SD). The mean manifest refraction SE (MRSE) and autorefractometer measurements and the autokeratorefractometer and corneal topography keratometry readings decreased significantly from preoperatively to 1 month postoperatively (P<.01) but did not change significantly thereafter (P>.05). Preoperatively, the mean uncorrected (UDVA) and corrected (CDVA) distance visual acuities were 0.21 ± 0.08 and 0.73 ± 0.08, respectively; postoperatively, the means were 0.73 ± 0.10 and 0.98 ± 0.05, respectively. All eyes achieved a postoperative UDVA better than 0.5. No eye lost CDVA lines. The safety index was 1.34. The mean MRSE was −5.18 ± 1.74 D preoperatively and −1.05 ± 0.64 D postoperatively (P<.01). Postoperatively, 11 eyes (91.67%) were within ±2.00 D of the SE, 8 (6.67%) were within ±1.00 D, and 5 (41.67%) were within ±0.50 D. No complications were encountered.
Treatment of post-DALK keratoconus patients with LASIK to correct manifest refraction error seems to be a viable option.
No author has a financial or proprietary interest in any material or method mentioned.
Combined Descemet-stripping automated endothelial keratoplasty and phacoemulsification with toric intraocular lens implantation for treatment of failed penetrating keratoplasty with high regular astigmatism
2012, Journal of Cataract and Refractive Surgery
Citation Excerpt :
In these cases, after the cornea has cleared following DSAEK, additional surgery is required to allow spectacle correction. Incisional surgery and/or excimer laser procedures (both photorefractive keratectomy and laser in situ keratomileusis) have been used in the past but have had variable refractive results, ie, undercorrection, overcorrection, and/or regression of effect over time, as well as relatively high rates of other complications, including perforation, wound gaping, infection, and loss of CDVA.14–19 Another option would be to combine cataract surgery with a repeat PKP, but this approach would expose the patient to a renewed higher immunologic risk as well as other PKP-related possible complications.
We present the case of a 57-year-old woman who had combined Descemet-stripping automated endothelial keratoplasty (DSAEK) and phacoemulsification with implantation of a toric intraocular lens (IOL). Surgery was intended to treat a cataract developing in a post-penetrating keratoplasty (PKP) eye with high astigmatism and endothelial decompensation. Six months after uneventful surgery, the cornea was clear and the corrected distance visual acuity was 20/20 with a refraction of +0.25 −1.00 × 10 (from −3.00 −8.50 × 12 preoperatively). The internal topography map (OPD-Scan) showed an IOL rotation of 4 degrees. The endothelial cell loss was 15% of the eye-bank value. Descemet-stripping automated endothelial keratoplasty combined with phacoemulsification and toric IOL implantation is a relatively simple and very effective procedure for eyes with endothelial failure and high post-PKP astigmatism. The speed of visual rehabilitation and final visual acuity achieved with this approach was superior to that obtained with other surgical procedures.
Dr. Busin received royalties from Moria in 2008, 2009, and 2010, and his travel expenses were partly reimbursed by Moria from 2005 to 2011. No other author has a financial or proprietary interest in any material or method mentioned.
Intrastromal corneal ring segment implantation for high astigmatism after penetrating keratoplasty
2009, Journal of Cataract and Refractive Surgery
Citation Excerpt :
However, to our knowledge, no study has evaluated differences in correction of post-PKP astigmatism based on the type of corneal disease before transplantation. Some studies do not mention the primary reason for PKP, and others include cases of bullous keratopathy and corneal dystrophy.17,18 The use of Kerarings with a 5.0 mm optical zone has 2 advantages over the use of Intacs (Addition Technology, Inc.), which have a 7.0 mm optical zone.
To evaluate the safety and efficacy of intracorneal ring segments (ICRS) for high astigmatism after penetrating keratoplasty (PKP).
Department of Ocular Surface and Inflammation, Ophthalmology, Hospital Clínico San Carlos, Complutense University, Madrid, Spain.
This retrospective noncomparative study comprised eyes with high post-PKP astigmatism (>4.00 diopters [D]), contact lens intolerance, and a minimum follow-up of 24 months who had ICRS (Kerarings) implantation by mechanical stromal dissection. Corrected distance visual acuity (CDVA), refractive astigmatism, spherical equivalent (SE), surgically induced astigmatism (SIA), central corneal curvature, topographic corneal astigmatism, average corneal power, and complications were assessed.
The mean CDVA was statistically significantly better postoperatively (0.23 ± 0.21) than preoperatively (0.98 ± 0.27) (P = .007); no eye lost CDVA. The mean refractive astigmatism decreased from 6.17 ± 1.12 D to 4.04 ± 1.67 D (P = .068) and the mean SE from −3.17 ± 5.48 D to −0.12 ± 2.40 D (P = .34). The mean SIA was 4.55 ± 2.83 D. The mean central corneal curvature decreased from 46.28 ± 1.73 D to 42.09 ± 3.20 D (P<.01); the mean topographic corneal astigmatism, from 7.07 ± 2.52 D to 4.48 ± 2.00 D (P<.05) and the mean average corneal power from 45.92 ± 1.59 D to 41.88 ± 3.37 D (P<.01); all decreases were statistically significant. One patient developed deep vascularization in the lower temporal stromal channel that resolved after ICRS removal. One patient reported significant night halos.
Implantation of ICRS for high post-PKP astigmatism reduced corneal curvature and topographic astigmatism, significantly improving CDVA.

View all citing articles on Scopus

¹: None of the authors has any proprietary or financial interest in any instrument discussed in this article.

View full text

Effect of hinged lamellar keratotomy on postkeratoplasty eyes 1

Abstract

Purpose:

Design:

Participants:

Intervention:

Main Outcome Measures:

Results:

Conclusions:

Section snippets

Patients and methods

Results

Refraction

Visual acuity

Corneal topography

Discussion

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

J Cataract Refract Surg.

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Residual corneal astigmatism after perforating keratoplasty

Ophthalmologica

Controlled reduction of post-keratoplasty astigmatism

The correction of post-keratoplasty astigmatism

Eye

Evaluation of penetrating keratoplasty in keratoconus. Nine years follow-up

Acta Ophthalmol (Copenh)

Complications post-opératoires à court, moyen et long terme sur 150 kératoplasties transfixiantes ayant au moins 1 an de recul

Ophtalmologie

The management of post-keratoplasty astigmatism by post-operative adjustment of a single continuous suture

Eye

Effect of hinged lamellar keratotomy on postkeratoplasty eyes ¹