Surgical Strategies To Clean Opaque Stromal Recipient Bed After Manual Deep Anterior Lamellar Keratoplasty

To describe two surgical approaches aimed at clearing the opaque stromal recipient beds of eyes undergone deep anterior lamellar keratoplasty (DALK) obtained after manual stromal dissection.

Two case reports of patients who underwent repeated keratoplasty procedures between February 2022 and March 2022 at “Magna Graecia” University of Catanzaro, Italy.

In the first case, a 31-year-old male with a history of keratoconus in the left eye underwent manual DALK in 2012. Nine years later, the patient came at our attention due to progressive visual impairment. Slit lamp examination revealed a vascularized central corneal leucoma, therefore a repeated DALK was planned. However, upon manual stromal dissection, intraoperative examination of the recipient bed revealed deep stromal opacities infiltrating Descemet membrane and endothelium. The residual stroma and endothelium-Descemet membrane complex in the optical zone (central 6.0 mm) was removed, preserving the healthy endothelium of the peripheral cornea. Then, a one-piece mushroom penetrating keratoplasty was performed, securing the graft on the recipient bed with interrupted sutures. In the second case, a 42-years-old female, diagnosed with keratoconus in the right eye, underwent 2 DALK surgeries. At the time of presentation due to limited visual acuity, the anterior segment optical coherence tomography revealed the persistence of significant irregularities and opacities at the level of the deep stromal interface. A concomitant failure of corneal endothelium was also detected. A modified descemetic stripping automated endothelial keratoplasty technique, which included the removal by means of a posterior approach of the deep stroma was performed. Six months after both surgeries, both grafts are transparent and well-adapted.

The present case series reports two successful surgical approaches that were customized for the single case in order to clean the opaque recipient bed after manual DALK.