Transcript Deep anterior lamellar keratoplasty in children

Deep anterior lamellar
keratoplasty in children
World Cornea Congress
April 2010
Boston, MA
Asim Ali, MD, FRCSC
University of Toronto
Hospital for Sick Children
Toronto, Ontario, Canada
Disclosure: The author has no financial interests related to the
material of this poster.
Abstract
Purpose
To present a series of pediatric patients who underwent deep anterior lamellar
keratoplasty (DALK) for stromal opacities or ectasia by one surgeon from 2007-2009.
Methods
A retrospective review of 12 consecutive patients with attempted DALK, age less than
18 years and follow-up of at least 4 months was performed. Indications for surgery,
length of follow-up, complications and initial and final visual acuity were recorded.
Results
Successful DALK was performed in 12 eyes of 11 patients aged 1-17 years old. There
was one macroperforation and conversion to penetrating keratoplasty. Non-healing
epithelial defects occurred in 2 patients who developed microbial keratitis. Repeat
DALKs were performed successfully. One patient developed reactivation of HSV in the
graft and because of dense amblyopia a repeat graft was not attempted. Final visual
acuity was unchanged or improved in all patients.
Conclusions
Deep anterior lamellar keratoplasty is a safe alternative to penetrating keratoplasty in
children with corneal stromal opacities or ectasia.
Methods



Records of 13 eyes of 12 consecutive
patients with attempted DALK were
reviewed
Single surgeon from 2007-09
Surgical technique used
◦ Melles technique (1 case)
◦ Manual dissection (12 cases)
 Trephination (Hessberg-Barron, 300-350 microns)
 Sharp and semi-sharp dissection to pre-Descemet’s
plane
 Air injected to visualize stroma but big bubble not
attempted
Results






12/13 eyes underwent successful manual DALK
1 eye was converted to PKP because of
macroperforation
4 microperforations occurred but dissection was
completed successfully
2 repeat DALKs (with tarsorraphy) were
performed after persistent epithelial defects
resulted in bacterial keratitis – both remain clear
Vision remains unchanged or improved in all
patients
Grafts are clear in 11/12 eyes with mean followup of 11.8 months (range 6-22)
Table 1: Pre-operative characteristics
Patie Age
nt
Eye
Diagnosis
Other
Pre-op
BCVA
1
9 mo
RE
Herpes simplex
CS UM*
2
9 yr
RE
Phlectenulosis
20/400
3
14 yr
RE
Keratoconus
14 yr
LE
Keratoconus
Fix + follow
4
15 yr
RE
Hurler syndrome
20/200
5
1 yr
LE
Corneal dermoid
6
8 yr
LE
? Herpes zoster
7
2 yr
LE
Bacterial keratitis
Neurotrophic cornea
8
16 yr
LE
Keratoconus
Eye-rubber, OCD, Tourettes CF
9
8 yr
RE
Descemetocele
Posterior blepharitis
20/40
10
14 yr
LE
Bacterial keratitis
Soft contact lens wearer
20/70
11
5 yr
RE
Exposure keratopathy
Goldenhar syndrome, lid
coloboma repair
20/800
12
13 yr
LE
Keratoconus
Autism, eye-rubber
Linear nevus sebaceous
Fix + follow
CS UM*
20/100
LP
CF
* Central, steady + unmaintained
Table 2: Operative details
Patient Eye
Residual
opacity
Donor/recipi Intraoperative complications /
ent (mm)
comments
1
RE
-
-
Macroperforation, converted to PKP
2
RE
No
7.75 /7.5
None
3
RE
No
7.75 /7.5
None
LE
No
8.0 /7.5
None
4
RE
Yes
8.0 /7.5
Microperforation
5
LE
No
7.0 /6.5
Previous crescentic graft, subsequent
cataract extraction /IOL /pupilloplasty
6
LE
Yes
8.0 /7.5
Microperforation
7
LE
No
7.25 /7.0
None
8
LE
No
8.5 /8.0
None
9
RE
Yes
7.75 /7.5
Microperforation
10
LE
No
8.25 /8.0
Microperforation
11
RE
No
7.75 /7.5
None
12
LE
No
8.0 /7.5
None
Table 3: Post-operative course
Patie
nt
Eye
Complications
Post-op
BCVA
Follow Comments
-up
1
RE
Graft rejection
20/200
2
RE
None
20/40
22 mo
3
RE
None
20/40
12 mo
LE
None
20/50
6 mo
4
RE
None
20/80
6 mo
Sutures in
5
LE
None
20/200
20 mo
Dense amblyopia
6
LE
Suture loosening at 6 weeks
20/60
11 mo
Amblyopia
7
LE
? HSV reactivation + scar
HM
13 mo
Opted not to regraft
8
LE
None
20/40
8 mo
9
RE
Persistent epi defect,
bacterial ulcer, regraft
20/40
22 mo
10
LE
None
20/20
12 mo
11
RE
Persistent epi defect,
bacterial ulcer, regraft
20/200
14 mo
12
LE
None
20/50
6 mo
Ambylopia
Tarsorraphy
Amblyopia
Figure 1:
Slit lamp photo of patient 6
showing anterior stromal scar
and thinning
Figure 2:
Slit lamp photo of patient 12
showing Vogt striae and deep
scarring
Discussion

DALK was selected instead of PKP in our pediatric patients because of a
lower risk of rejection and greater tectonic strength. Two of our patients
(3 and 8) were forceful eye rubbers with psychiatric co-morbidities and the
improved strength was reassuring.

A manual technique instead of a big bubble technique was used to allow
dissection of deep scars and minimize perforations, as we believe the
benefit of reduced rejection outweighs the visual benefits in this patient
group with other ocular co-morbidities especially amblyopia.

The high rate of perforation may reflect the deep scarring in some corneas
and also surgeon inexperience.

Satisfactory visual outcomes were achieved even when residual corneal
opacities remained in the recipient bed.

Persistent epithelial defects lead to bacterial superinfection in two patients
and we now perform temporary and permanent tarsorraphies following
DALK surgery in susceptible patients.
Conclusions

Manual DALK in children leads to
improved visual outcomes, and in our
view has significant advantages over PKP
in this high risk group.