P-15 Utilising endothelial migration to perform deep anterior lamellar keratoplasty in eyes with deep posterior corneal scarring typically treated with penetrating keratoplasty. (26th May 2022)

• Record Type: Journal Article
• Authors: García-Onrubia, Luis; Stanojcic, Nick; Bhogal, Maninder
• Is Part Of: BMJ open ophthalmology. Volume 7(2022)Supplement 1
• Page Start: A4
• Page End: A5
• Publication Date: 2022-05-26
• Subjects: Ophthalmology -- Periodicals; 617.7005
• DOI: 10.1136/bmjophth-2022-BCM.12
• Languages: English
• ISSNs: 2397-3269

Abstract

Abstract : *Correspondence - Luis García-Onrubia: [e-mail] Purpose: To describe a novel technique for deep anterior lamellar keratoplasty (DALK) in patients central corneal perforation and deep scarring making conventional DALK (Melles or Big Bubble) unviable. A posterior Descemet's membrane (DM) skirt has provided an adequate scaffold for the migration of the host endothelial cells. Methods and Analysis: A case report. A 32-year-old male with previous hydrops developed severe corneal scarring with a break in DM visible on OCT scanning. A modified DALK procedure was perform consisting of a 400µm, 8.5mm Anterior lamellar cap with a 4.5mm posterior lamellar disc, denuded of endothelial cells and containing a DM skirt. Initially, manual dissection of the and anterior 400µm of corneal stroma was performed using a modified Melles technique. The residual posterior lamellar was assessed and found to have significant residual scarring. A central 4mm optical window was performed through the posterior lamellar over the visual axis. The donor tissue was cut using a 350µm microkeratome head. The anterior cap was trephined to 8.5mm and set aside. The posterior lamellar was placed in a punch block, and the endothelial was removed using a silicone tipped cannula. The removal of endothelial cells was confirmed using trypan blue dye. A posterior lamellar graft with a 4.0mm stromal bed and a 4.5mm DM skirt was fashion using a peeling and double punch technique. The posterior lamellar graft was inserted into the optical window such that the DM skirt provided a bridge to the donor corneal endothelium. The anterior cap was sutured with a double continuous suture of 10–0 monofilament nylon. An inferior peripheral iridotomy was created, and an air bubble filling the anterior chamber was left at the end of the case. Results: The preoperative visual acuity (VA) was hand movements. Full attachment of the posterior lamellar was seen at all time-points from week one onwards. Central corneal pachymetry continued to reduce for 12 weeks. One year after the operation, with sutures in, the best spectacle-corrected VA was 6/12. The corneal graft was clear, and no rejection episodes occurred. Endothelial cell repopulation of the donor DM could be observed with specular microscopy. Conclusion: The presence of DM promotes endothelial migration and healing. Modifications to traditional DALK surgery, in which DM is used to promote endothelial healing, are a viable alternative to penetrating keratoplasty. This method eliminates the risk of allograft endothelial rejection and allows a 'regenerative' for DALK to be used, offering a new modality of treatment in patients with healthy reserves of endothelial cells and deep posterior lamellar scarring.