Elsevier

Ophthalmology

Volume 119, Issue 2, February 2012, Pages 249-255
Ophthalmology

Original article
Long-term Results of Deep Anterior Lamellar versus Penetrating Keratoplasty

https://doi.org/10.1016/j.ophtha.2011.07.057Get rights and content

Objective

To compare deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in eyes with corneal diseases not involving the corneal endothelium (keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma).

Design

Retrospective, comparative case series.

Participants

One hundred forty-two consecutive DALK (DALK group; big-bubble technique or manual lamellar dissection using a slitlamp) and 142 matched PK (PK group).

Methods

Three models were used to describe the postoperative outcomes of the endothelial cell density. A joint regression model was used to predict long-term graft survival. Visual acuity, ultrasound pachymetry, specular microscopy, and optical coherence tomography (OCT) findings were recorded.

Main Outcome Measures

Postoperative endothelial cell loss and long-term predicted graft survival.

Results

The average 5-year postoperative endothelial cell loss was −22.3% in the DALK group and −50.1% in the PK group (P<0.0001). The early- and late-phase annual rates of endothelial cell loss were −8.3% and −3.9% per year, respectively, in the DALK group and −15.2% and −7.8% per year in the PK group (P<0.001; biphasic linear model). The median predicted graft survival was 49.0 years in the DALK group and 17.3 years in the PK group (P<0.0001). The average visual acuity was lower in the manual dissection subgroup compared with the PK group (average difference, 1.0 to 1.8 line) and with the big-bubble subgroup (average difference, 2.2 to 2.5 lines). The average central corneal thickness at 12 months was 536 μm in the PK group, 523 μm in the big-bubble subgroup, and 562 μm in the manual dissection subgroup (P<0.001). The average thickness of the residual recipient stroma measured by OCT was 87±26 μm in the manual dissection subgroup. No correlation was found between this figure and logarithm of the minimal angle of resolution at any postoperative time point (P>0.05).

Conclusions

Long-term, model-predicted graft survival and endothelial densities are higher after DALK than after PK. The big-bubble technique gives better results than manual dissection and PK. Compared with PK, manual dissection provides higher survival of both the corneal endothelium and graft, but lower visual acuity.

Financial Disclosure(s)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Section snippets

Study Design

This retrospective, comparative case series was designed from a consecutive series of keratoplasties performed in a single center. Inclusion criteria were keratoplasty procedures performed by 1 surgeon (V.M.B.) between January 1995 and April 2010 for optical indications in eyes with corneal diseases not involving the corneal endothelium (i.e., keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma). For patients who received 2 grafts in the same or contralateral eye

Results

Table 1 shows the baseline comparison of the DALK group with the PK group. We examined 142 (100%), 134 (94.4%), 108 (76.1%), and 80 (56.3%) eyes at 0, 12, 24, and 36 months in the DALK group, respectively. In the PK group, these figures were 142 (100%), 134 (94.4%), 123 (86.6%), and 112 (78.9%), respectively.

In the DALK group, graft failures were the result of persistent postoperative double anterior chamber (n = 1), late infectious keratitis (n = 1), and trauma (n = 1). In the PK group, they were the

Discussion

In this retrospective study of patients with keratoconus, corneal scars after infectious keratitis, stromal dystrophies, and trauma, long-term model-predicted graft survival was dramatically greater in the DALK group than in the PK group. The median model-predicted graft survival was 49 years in the DALK group and 17.3 years in the PK group. This implies that a young patient undergoing DALK should not require regrafting in the long term. Conversely, regrafting is likely to be required in the

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    Manuscript no.: 2011-762.

    Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

    Supported by Université Pierre et Marie Curie-Paris6, Paris, France. The sponsor or funding organization had no role in the design or conduct of this research.

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