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Mid-stromal lamellar keratoplasty: a new surgical technique for advanced keratoconus

Poster Details

First Author: M.Khan UK

Co Author(s):    J. Martin   P. Mathewson   S. Shah              

Abstract Details


Keratoconus is a visually debilitating, progressive corneal ectasia with a range of management options depending on the degree of progression. The pathophysiological hallmark includes apical stromal thinning with associated irregular astigmatism. Bowman layer transplantation has recently been described however the difficulty in graft preparation and transplantation here results in a steep learning curve. We report an entirely novel surgical technique and the world�â�€�™s first mid-stromal lamellar keratoplasty (MSLK) for advanced keratoconus. The underlying premise being that the added mid-stromal bulk will thicken, strengthen and flatten the central corneal architecture thereby helping to reduce the irregular astigmatism.


Birmingham Midland Eye Centre, Birmingham, UK


Our patient was a 28 year old male with advanced keratoconus and contact-lens intolerance. The graft lenticule was prepared using the Gebauer SLc Expert microkeratome system to a thickness of 100um with a 7mm diameter and a planar profile. A mid-stromal pocket was created manually, as in DALK, and the lenticule was positioned into the pocket with an ACIOL glide. The mid-stromal graft was then cross-linked with riboflavin within the intrastromal pocket (9mW of UV light over 9 minutes). A number of measurements were obtained pre-operatively and at various stages post-operatively. This included pachymetry, topography, AS-OCT and intra-ocular pressure.


Our early results are promising. At 4 weeks post-operatively, there was a significant improvement in topographic cylinder (astigmatism improved by 3 dioptres) and central corneal thickness increased by almost 100um (from 425um to 521um). The intra-ocular pressure increased by about 3mmHg both with iCare and Goldmanns applanation tonometry. The anterior segment OCT images showed a well-positioned, mid-stromal lamellar graft.


We report an entirely novel surgical technique for the management of advanced keratoconus and the world's first mid-stromal lamellar keratoplasty. MSLK offers a number of advantages over Bowman layer transplantation including a thicker lenticule (100um vs 17um for Bowman layer), easier and quicker graft preparation with reduced theoretical risk of graft damage and a more favourable learning curve. MSLK offers an exciting way forward for the management of advanced keratoconus and may offer a viable alternative to DALK or PK.

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