Acta Ophthalmologica 2008

Longterm results of deep lamellar keratoplasty using grafts with endothelium

Shiro Higaki,1 Yuichi Hori,2 Naoyuki Maeda,2 Hitoshi Watanabe,2 Yoshitsugu Inoue3 and Yoshikazu Shimomura1
1 Department of Ophthalmology, Kinki University School of Medicine, Osaka, Japan 2 Department of Ophthalmology, Osaka University Medical School, Osaka, Japan 3 Division of Ophthalmology, Faculty of Medicine, Tottori University, Tottori, Japan

ABSTRACT. Purpose: To report the longterm results of deep lamellar keratoplasty (DLK) using grafts with their own endothelia. Methods: Fourteen eyes of 14 patients underwent DLK using grafts with endothelium. The average follow-up was approximately 80.0 months. Preoperative diagnoses included: corneal leukoma (ve eyes); gelatinous drop-like corneal dystrophy (three eyes); Avellino corneal dystrophy (two eyes); corneal perforation (two eyes); corneal mucopolysaccharidosis (one eye), and keratoconus (one eye). Results: Corrected visual acuity was improved in 13 eyes (93%), but ruptures of Descemets membrane occurred in six eyes (43%) and a double anterior chamber was found in ve eyes (36%) postoperatively. Despite this, all grafts remained clear as a result of their functioning endothelia. Conclusions: Deep lamellar keratoplasty using a graft with its own endothelium is a safe and valuable procedure with exibility and feasibility that should suit corneal surgeons of all levels.
Key words: deep lamellar keratoplasty double anterior chamber penetrating keratoplasty endothelium

Acta Ophthalmol. 2008: 86: 4952

2007 The Authors Journal compilation 2007 Acta Ophthalmol Scand

doi: 10.1111/j.1600-0420.2007.01004.x

Introduction
There are many reports of deep lamellar keratoplasty (DLK) carried out in patients with normal corneal endothelium (Archila 19841985; Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al.

2004; Wylegala et al. 2004; Shimmura et al. 2005). The advantages of DLK over penetrating keratoplasty include the elimination of endothelial rejection and the superior restoration of postoperative visual acuity (VA) (Shimazaki et al. 2002; Watson et al. 2004). Although penetrating keratoplasty results in good enough postoperative VA, endothelial rejection and

continuous endothelial cell loss are often encountered (Bourne et al. 1994; Lyons et al. 1994; Serdarevic et al. 1994; Krohn & Hovding 2005; Bertelmann et al. 2006). These phenomena do not occur with DLK. However, that DLK is a time-consuming procedure and that it occasionally involves the postoperative development of a double anterior chamber remain problems to be resolved (Archila 1984 1985; Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). The original technique used in DLK involved using a donor cornea with its own endothelium (Archila 19841985). Recent reports have mainly described cases of donor corneas without endothelia (Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). The benets of using a donor cornea without the endothelium in DLK include the convenience of using preserved corneas. Sugita & Kondo (1997) reported a study of 120 DLK cases. The donor corneas used in this study were full-thickness fresh corneas in 16 eyes, corneas with removed endothelium and Descemets membrane in 50 eyes, and corneas

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cryolathed from the endothelial side to a thickness of approximately 0.4 mm in 54 eyes. The study showed that postoperative transparency was achieved faster in eyes that received fresh corneas, but similar results were observed later in eyes that received donor corneas which had been frozen and preserved (Sugita & Kondo 1997). Similarly, Tsubota et al. (1998) removed the endothelium and 30% of the stroma from the fresh donor corneas in their DLK operations. They divided the recipient cornea into four quadrants to facilitate lamellar dissection and continued this procedure until Descemets membrane was exposed in the central area. They reported a mean best corrected visual acuity (BCVA) of 20 52 in 17 eyes of 15 patients at 6 months after DLK (Tsubota et al. 1998). By contrast with recent studies, we consider that using a donor cornea with its own endothelium in DLK is advantageous because it allows the surgeon the exibility to change the planned DLK to penetrating keratoplasty if a complication occurs during surgery. In addition, even if a double anterior chamber is observed postoperatively, the donor cornea will still be transparent because the grafts

endothelium is present and functioning. Here we report the longterm results of our DLK cases using this technique.

Materials and Methods

Fourteen eyes of 14 patients (six men and eight women; mean age 47.8 19.8 years [mean standard deviation]) were treated with DLK from June 1994 to October 1999 (Table 1). Follow-up periods ranged from 55 to 113 months (mean 80.4 13.6 months). The pre-DLK pathologies were: corneal leukoma (ve eyes); gelatinous drop-like corneal dystrophy (three eyes); Avellino corneal dystrophy (two eyes); corneal perforation (two eyes); corneal mucopolysaccharidosis (one eye), and keratoconus (one eye). The recipient cornea was rst trephined to three-quarters of its depth with a 7.25- 7.5- or 7.75-mm diameter Hessburg)Barron disposable trephine (JEDMED Instrument Co., St Louis, MO, USA) before lamellar keratectomy was performed. The lamellar dissection was performed with a disposable blade and a spatula using the intrastromal air injection

technique (Archila 19841985; Chau et al. 1992). When Descemets membrane was ruptured, air was injected into the anterior chamber at the end of surgery. For the donor cornea, a fresh sclerocorneal button which had been stored in Optisol (Bausch & Lomb, Irvine, CA, USA) was trephined from the endothelial side to a diameter of 7.5, 7.75 or 8.00 mm. The donor corneas used in our study were of full thickness and retained their own endothelia. In most cases, eight interrupted 100 nylon sutures were initially used to secure the corneal button in the recipients bed and were followed by a single continuous running suture with 16 bites. In some cases, only 16 interrupted sutures were needed. Therapeutic contact lenses were placed on some of the corneas. At the end of surgery, 2 mg dexamethasone was injected into the subconjunctival area. Topical corticosteroid (0.1% betamethasone) and antibiotics (ooxacin) four times a day were prescribed. Corneal graft examination and VA measurements were carried out postoperatively at 1 week and at 1, 2, 3, 6, 9 and 12 months, and yearly thereafter.

Table 1. Overviews of 14 cases of deep lamellar keratoplasty. Age (years) 67 63 69 66 58 33 54 Intra- postoperative complications Descemets membrane rupture, double chamber Descemets membrane rupture, double chamber, anterior chamber bleeding Descemets membrane rupture Descemets membrane rupture, double chamber Descemets membrane rupture, double chamber Descemets membrane rupture, double chamber Follow-up (months) 86 72 72 82 70 113 89

Case 1 2 3 4 5 6 7

Disease Leukoma Leukoma Leukoma Leukoma Leukoma Gelatinous drop-like dystrophy Gelatinous drop-like dystrophy recurrence Gelatinous drop-like dystrophy recurrence Avellino corneal dystrophy recurrence Avellino corneal dystrophy recurrence Perforation Perforation Mucopolysaccharidosis Keratoconus

Sex M F F F F M M

Pre-DLK VA HM CF 20 630 20 100 20 100 20 1000 HM

Post-DLK VA 20 40 20 200 20 50 20 50 20 25 20 30 20 40

Comments

Macular degeneration (+)

8 9 10 11 12 13 14

30 68 30 19 65 21 26

F M F F M F M

HM 20 63 20 2000 20 1000 20 2000 20 400 20 630

20 50 20 20 20 500 20 200 20 2000 20 100 20 30

72 75 55 88 87 90 74 Stromal opacity from herpes (+) Avellino recurrence (+)

DLK deep lamellar keratoplasty; VA visual acuity; M male; F female; HM hand movements; CF counting ngers.

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Results
Best corrected VA improved in 13 of the 14 eyes (93%) (Table 1). Rupture of Descemets membrane occurred in six eyes (43%) and was treated by injecting air into the anterior chamber at the end of surgery. A double anterior chamber occurred postoperatively in ve eyes (36%; cases 2, 7, 11, 12 and 13) and disappeared spontaneously within 1 week in three eyes (cases 7, 11 and 12). In case 2, air was injected on postoperative day 9 and the double anterior chamber disappeared on the following day. Despite the existing double anterior chamber, the graft in case 13 remained clear because its own endothelium was functioning normally. There were no episodes of endothelial rejection in any of the eyes. In case 10, although Descemets membrane ruptured during DLK, no double anterior chamber was observed after surgery.
Case reports Case 6 (Table 1)

Fig. 1. Photograph of persisting double anterior chamber in case 13 at 14 months after surgery. The graft, with its own endothelium, remained clear. The host Descemets membrane is shown.

This case involved a 33-year-old man with gelatinous drop-like corneal dystrophy in both eyes. Preoperative VA in the right eye was 20 1000. Deep lamellar keratoplasty and keratoepithelioplasty (Turgeon et al. 1990) were performed in December 1995. Without being ruptured, Descemets membrane was exposed over a central area with a 5-mm diameter. The prepared corneal button was sutured on the recipients bed with eight interrupted sutures and a single continuous running 100 nylon suture with 16 bites. At 38 and 113 months postsurgery, VA was 20 30.
Case 13 (Table 1)

anterior chamber. The photograph of these cysts taken by UBM has been presented previously by our group (Sato et al. 2002). Based on these observations, we decided that it would be too risky to inject additional air into the anterior chamber in this case. A double anterior chamber formed (Fig. 1) and has persisted to date for 90 months after surgery. Nevertheless, the graft with its own endothelium did not become oedematous. At the last follow-up, the patients BCVA was 20 100 and the graft remained clear.

Discussion
Our study showed that, for the treatment of corneal opacities with normal corneal endothelium, DLK using the donor endothelium was of greater value than DLK without the endothelium. As many DLK cases show, rupture of Descemets membrane and the presence of a double anterior chamber represent complications that are frequently encountered, even by experienced surgeons (Archila 19841985; Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). Rupture of Descemets membrane and the development of a double anterior chamber are reported to occur at rates of 1550% (Sugita & Kondo 1997; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al.

A 21-year-old woman had opacied corneas caused by mucopolysaccharidosis in both eyes. Preoperative VA in the left eye was 20 400; this eye underwent DLK in December 1997. Dissection of the stroma was very difcult because of corneal mucopolysaccharidosis. Descemets membrane ruptured and air was injected into the anterior chamber. On the following day, air was observed between the iris and lens by slit-lamp examination, and there was almost no anterior chamber. Ultrasound biomicroscopy (UBM) showed that cysts under the iris had caused the narrowing of the

2004; Shimmura et al. 2005) and 025% (Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Shimmura et al. 2005), respectively. In recent years, DLK using the donor cornea without the endothelium has been commonly performed (Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). When DLK is performed using a donor cornea without the endothelium and a double anterior chamber develops, injecting air or SF6 gas into the anterior chamber in order to correct the double anterior chamber will occasionally be necessary. However, gas injection can cause pupillary blocks, angle closure and irreversible mydriasis. By contrast, when a double anterior chamber occurs in DLK using a donor cornea with endothelium, using gas injection to cancel the double anterior chamber promptly is not necessary and thus the undesirable complications caused by gas injection can be avoided. As seen in case 13 in this study (Table 1), despite the existing double anterior chamber, the graft remained clear because its endothelium functioned properly. However, if a graft without endothelium had been used, it would have become oedematous when a double anterior chamber developed. We previously reported a case where penetrating keratoplasty using the donor cornea with the endothelium

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Acta Ophthalmologica 2008

was the procedure initially planned to treat corneal stromal opacity in a patient with normal corneal endothelium (Higaki et al. 1999). As in case 13 here, the procedure resulted in a double anterior chamber because the host Descemets membrane became inadvertently detached during the surgery. Despite the presence of the host Descemets membrane, excellent recovery of the patients VA was achieved because of the functioning donor endothelium. These results showed that our technique of using the graft with its endothelium can produce good results, even in cases of Descemets membrane rupture and a double anterior chamber. Slit-lamp examination indicated no opacity between the graft and the recipients cornea in any of our cases. Moreover, the post-DLK restoration of VA in our cases was comparable with results in previous reports (Archila 19841985; Chau et al. 1992; Sugita & Kondo 1997; Tsubota et al. 1998; Melles et al. 1999; Coombes et al. 2001; Shimazaki et al. 2002; Watson et al. 2004; Wylegala et al. 2004; Shimmura et al. 2005). Another advantage of this technique is that it allows the surgeon to switch from the planned DLK procedure to a penetrating keratoplasty if any intraoperative complication such as Descemets membrane rupture covering more than 25% of cornea occurs. Furthermore, this technique does not require any lathing (Chau et al. 1992; Sugita & Kondo 1997) or removal of the grafts endothelium and stroma, thus reducing the tasks involved in the procedure. However, the donor cornea must be fresh for DLK using a graft with endothelium, which denies the convenience of using a preserved cornea (Chau et al. 1992; Sugita & Kondo 1997). In addition, the risk of rejection of fresh tissue compared with freeze-dried or other non-viably stored tissue may become problematic, although this did not arise in our cases. Recently, the results of automated lamellar therapeutic keratoplasty (ALTK) (Vajpayee et al. 2006) have

been reported. Although this procedure requires special devices, it has been thought to be safe and effective for diseases affecting the anterior to mid-stroma of the cornea. We intend to compare the results of ALTK with those of DLK. In conclusion, given the merits described above, DLK using a donor cornea with its own endothelium is benecial and feasible. Moreover, because this technique requires fewer tasks to be carried out and has a lower risk for adverse events occurring during the procedure, it can be performed safely by less experienced or occasional corneal surgeons.

References
Archila EA (19841985): Deep lamellar keratoplasty dissection of host tissue with intrastromal air injection. Cornea 3: 217 218. Bertelmann E, Pleyer U & Rieck P (2006): Risk factors for endothelial cell loss postkeratoplasty. Acta Ophthalmol Scand 84: 766770. Bourne WM, Hodge DO & Nelson BA (1994): Corneal endothelium 5 years after transplantation. Am J Ophthalmol 118: 185196. Chau GK, Dilly SA, Sheard CE et al. (1992): Deep lamellar keratoplasty on air with lyophilised tissue. Br J Ophthalmol 76: 646 650. Coombes AG, Kirwan JF & Rostron CK (2001): Deep lamellar keratoplasty with lyophilised tissue in the management of keratoconus. Br J Ophthalmol 85: 788791. Higaki S, Maeda N, Watanabe H et al. (1999): Double anterior chamber deep lamellar keratoplasty: case report. Cornea 18: 240242. Krohn J & Hovding G (2005): The inuence of donor age and cause of death on corneal endothelial cell density. Acta Ophthalmol Scand 83: 746750. Lyons CJ, McCartney AC, Kirkness CM et al. (1994): Granular corneal dystrophy: visual results and pattern of recurrence after lamellar or penetrating keratoplasty. Ophthalmology 101: 18121817. Melles GRJ, Landers F, Rietveld FJR et al. (1999): A new surgical technique for deep stromal, anterior lamellar keratoplasty. Br J Ophthalmol 83: 327333. Sato S, Inoue Y, Shimomura Y et al. (2002): Multiple iridociliary cysts in patients with

mucopolysaccharidoses. Br J Ophthalmol 86: 933934. Serdarevic ON, Renard GJ & Pouliquen Y (1994): Randomized clinical trial comparing astigmatism and visual rehabilitation after penetrating keratoplasty with and without intraoperative suture adjustment. Ophthalmology 101: 990997. Shimazaki J, Shimmura S, Ishioka M et al. (2002): Randomized clinical trial of deep lamellar keratoplasty versus penetrating keratoplasty. Am J Ophthalmol 134: 159 165. Shimmura S, Shimazaki J, Omoto M et al. (2005): Deep lamellar keratoplasty (DLKP) in keratoconus patients using viscoadaptive viscoelastics. Cornea 24: 178181. Sugita J & Kondo J (1997): Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol 81: 184188. Tsubota K, Kaido M, Monden Y et al. (1998): A new surgical technique for deep lamellar keratoplasty with single running suture adjustment. Am J Ophthalmol 126: 18. Turgeon PW, Nauheim RC, Roat MI et al. (1990): Indications for keratoepithelioplasty. Arch Ophthalmol 108: 233236. Vajpayee RB, Vasudendra N, Titiyal JS et al. (2006): Automated lamellar therapeutic keratoplasty (ALTK) in the treatment of anterior to mid-stromal corneal pathologies. Acta Ophthalmol Scand 84: 771773. Watson SL, Ramsay A, Dart JK et al. (2004): Comparison of deep lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus. Ophthalmology 111: 16761682. Wylegala E, Tarnawska D & Dobrowolski D (2004): Deep lamellar keratoplasty for various corneal lesions. Eur J Ophthalmol 14: 467472.

Received on November 20th, 2006. Accepted on June 6th, 2007. Correspondence: Shiro Higaki Department of Ophthalmology Kinki University School of Medicine 3772 Ohno-Higashi Osaka-Sayama Osaka 589-0014 Japan Tel: + 81 72 366 0221 Fax: + 81 72 368 2559 Email: higaki@ganka.med.kindai.ac.jp

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