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H. E. Kaufman, A. A. Abdelkader; Deep Anterior Lamellar Keratoplasty With and Without Exposure of Descemet’s Membrane: Clinical and Confocal Microscopic Study. Invest. Ophthalmol. Vis. Sci. 2007;48(13):1135.
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To evaluate the clinical findings, visual outcomes and in vivo confocal microscopic features of the lamellar interface and wound margin in both maximum depth anterior lamellar keratoplasty (MD-ALKP) when Descemet’s membrane (DM) was bared and deep anterior lamellar keratoplasty (DLKP) when the most posterior recipient stroma was spared.
DLKP was performed on 20 eyes of 20 patients with corneal pathologic features without DM or endothelial abnormalities. DM was totally bared at least in the optical zone for 12 eyes using the big air bubble technique. Sparing of the most posterior stroma was intentionally performed for the remaining 8. A full-thickness graft devoid of endothelium and DM was then sutured in place. Median follow up period was 10 months.
No patient required conversion to PK intraoperatively. One eye had persistent epithelial defect due to a lax eyelid with severe stromal inflammation and is scheduled for PKP. In MD-ALKP patients where DM was exposed, 10 of 11 eyes achieved BCVA of 20/30 or better at 6 months, and 6 of 11 achieved BCVA of 20/20 at 6 months. In the DLKP group where a very fine layer of the deepest stroma was spared, 6 of 8 eyes achieved BCVA of 20/30 or better at 6 months. The density, brightness and reflectivity of activated keratocytes at the interface were less in MD-ALKP group compared to DLKP group 7 days after surgery. Ten to 12 weeks after DLKP (4-6 weeks after MD-ALKP), keratocyte morphology, density and reflectivity had returned to normal. Activated keratocytes were denser around the sutures in both groups. The interface reflectivity was highest at 7- 21 days in MD-ALKP group and in DLKP group, it was highest at 15 days to 2 months and presented in both groups as a subsequent, progressive decrease in reflectivity, indicating tissue transparency was regained. Mean topographic astigmatism was 3.69 ± 0.84 D at 3 months (Sutures on), and 2.17 ± 0.75 D at 6 months with sutures out.
DLKP is a safe, effective procedure with little threat of rejection, preservation of the patient's endothelium, and visual results that compare favorably with PKP. The tectonic strength of the lamellar keratoplasty wound was derived from the sutures evidenced by many activated keratocytes around the sutures which enhance the wound edge healing response that acts as a belt preventing keratoectasia.
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