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Why should we perform deep anterior lamellar keratoplasty by big-bubble technique?

Poster Details

First Author: J.McCulley USA

Co Author(s):    E. Mohamed   J. Arciniega   R. Bowman        

Abstract Details


To evaluate the endothelial cell density (ECD) loss, visual and refractive outcomes, complications, and corneal graft survival rates in a consecutive series of deep anterior lamellar keratoplasties (DALKs) using the big-bubble (BB) technique.


Department of Ophthalmology, Hospital de Santo António-Centro Hospitalar do Porto, Porto, Portugal


Retrospective, consecutive, noncomparative case series of fifty-one eyes of forty-seven patients who underwent DALK for the treatment of corneal stromal diseases not affecting the endothelium at a single institution between 2008 and 2011. All information was obtained retrospectively from the medical records. DALK was performed using the BB technique, and a full-thickness donor cornea without Descemet membrane was sutured to the recipient bed. Demographics, preoperative and postoperative ECD, uncorrected visual acuity (UCVA) (Snellen), best-spectacle corrected visual acuity (BSCVA) (Snellen), refractive and topographic astigmatism, and intraoperative and postoperative complications were considered in the analysis. Cases with a minimum follow-up of 6 months were included in the statistical analysis.


Fifty-one eyes of forty-seven patients with a mean age of 51 years were followed for a median of 21 months (range 6–46 months). Twenty-seven patients (58%) were male. Predominant indications for DALK in this series were keratoconus (78%), postherpetic keratitis scarring and corneal stromal opacities of different etiologies (22%). BB was achieved in forty-two eyes (82%) and in the remaining nine eyes (18%) a BB separation of the DM was not possible necessitating manual lamellar dissection of stroma. Intraoperative Descemet’s membrane microperfuration occurred in 5 cases (10%). Mean preoperative ECD was 2509 cells/mm²; 12 months after surgery the mean ECD reduced to 2311 cells/mm². Mean(± SD) endothelial cell loss from preoperative levels averaged 7.9%±4.8% at 12 months. Baseline UCVA and BSCVA was <0.05 in 74% and in 64%,respectively; [0.05-0.1] in 22% and in 28%,respectively.After 12 months, the mean UCVA remained ?0.1 in 58% and improved to [0.2-0.4] in 52% and to [0.5-0.7] in 10%; the mean BSCVA improved to [0.2-0.4] in 22%, to [0.5-0.7] in 36% and to [0.8-1.0] in 42%.


In this study we concluded that DALK is a successful option for visual rehabilitation of stromal corneal pathology with healthy endothelium, with good ECD at least 6 months postoperatively. From these results it seems that there is no advantage to DALK for refractive error outcome compared to penetrating keratoplasty. Although technically more demanding, DALK has the advantage of preservation of the patient's endothelium which may result in better long-term graft survival. Descemet's membrane perforation was the major intraoperative complication in DALK in our series. FINANCIAL DISCLOSURE?: No

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