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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 21-23

Indications and Clinical Outcome of Deep Anterior Lamellar Keratoplasty (Dalk) In Central India


Senior Resident, Department of Ophthalmology, Darbhanga Medical College, Darbhanga, Bihar, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Seema Kumari
Senior Resident, Dept. of Ophthalmology, DMCH, Darbhanga, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Aim: To report clinical outcomes of deep anterior lamellar keratoplasty (DALK) in patients with varied corneal opacities.
Design: Retrospective noncomparative interventional study.
Methods: 54 patients were subjected to DALK and followed for at least six months. Outcome measures were intraoperative and postoperative complications, uncorrected and best corrected visual acuity (UCVA and BCVA), mean refractive spherical equivalent (MRSE) and mean cylinder at final follow-up.
Results: Intraoperative complications includes Descemet's perforation (6). Postoperative complications includes interface haze (4), graft infection (3), pupillary block glaucoma (1), graft melting (1), graft rejection (3). Mean preoperative and postoperative UCVA and BCVA was 1.56±0.35D; 1.09±0.47D and 1.56+0.35D;0.76+0.54D respectively. Mean MRSE and mean cylinder at final follow up was -0.76+5.94DS and 0.41±10.72D respectively.
Conclusion: DALK provides stable long term visual and refractive outcomes.

Keywords: Deep anterior lamellar keratoplasty, graft rejection


How to cite this article:
Kumari S. Indications and Clinical Outcome of Deep Anterior Lamellar Keratoplasty (Dalk) In Central India. J Indira Gandhi Inst Med Sci 2018;4:21-3

How to cite this URL:
Kumari S. Indications and Clinical Outcome of Deep Anterior Lamellar Keratoplasty (Dalk) In Central India. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:21-3. Available from: http://www.jigims.co.in/text.asp?2018/4/2/21/302948




  Introduction: Top


In a developing country like India where blindness due to corneal diseases is on a rising tide, lamellar keratoplasty has proved to be a boon. Twenty first century is an era of custom keratoplasty. It aims at selectively treating only the diseased portions of cornea. A wide deficit exists between corneal demand and supply. In this regard lamellar keratoplasty have gained an edge. A single good quality cornea can be used in three patients, lamellar grafts up to posterior stroma can be used for DALK (Deep Anterior Lamellar Keratoplasty), Descemet's with endothelium can be used for DSEK (Descemet's Stripping Endothelial Keratoplasty), cornea scleral rim can be used for limbal stem cell deficiency (LSCD). Among lamellar keratoplasty DALK has an edge over penetrating keratoplasty.[2] DALK eliminates the risk of endothelial rejection by selectively replacing the pathological corneal layer while preserving the healthy endothelium.[1] The requirements for DALK are a healthy recipient ocular surface, an adequate endothelial cell function, a corneal opacity that spares DM and a grossly distorted corneal surface that precludes contact lens fit. DALK offers an edge as corneas with low endothelial counts can be used.[2] Inferior quality corneas can be used in DALK with good results. DALK can be done in corneas of varied opacities like keratoconus stromal dystrophies and corneal scars. The extraocular nature of this procedure and a greater wound strength are added advantages of DALK.[2] This study was done with the view of reporting clinical outcomes of deep anterior lamellar keratoplasty (DALK) in patients with varied corneal opacities.


  Materials and Method: Top


Retrospective review of clinical records of 54 eye of 54 patients of DALK was done. Cases included were corneal opacities of varied causes. Study location was Department of cornea Sadguru Netra Chikitsalaya Chitrakoot, India. Exclusion criteria was patients with incomplete documentation, follow up of less than 3 months and other ocular co-morbidities like patients with any posterior segment pathologies, secondary glaucoma and derangements of anterior segment were excluded from the study. The Statistical analysis was performed by STATA 11.2 (College Station TX USA). Shapiro Wilk test were used to find normality. Wilcoxon sign rank test were used to find the pre and post significance difference between the Log Mar uncorrected visual acuity. P<0.05 was considered as statistically significance. Data collected included patients age at operation, indication for operation, pre and postoperative keratometry, pre and post-operative Best corrected visual acuity (BCVA), astigmatism, length of follow up and complications. Slit lamp examination for signs of graft rejection, inflammation, uveitis, neovascularisation; wound integrity, graft haze or interface haze, intraocular pressure by NCT, suture removal and graft clarity.


  Results: Top


Our study included 54 eyes from 54 patients. 24 were male 30 were female. The most common indication for DALK in our study was keratoconus 26 cases (48.1%) This was followed by corneal dystrophies (macular dystrophy)-9 cases (16.6 %), corneal scarring -9cases (16.6 %), corneal degeneration -7cases (12.9 %) and post microbial keratitis scarring -1 case (1.8 %), scarring post lime injury 2 cases (3.7%). The records reviewed that that donor tissue was procured from two sources, one from Sadguru eye bank and second from other eye bank and were transplanted before expiry dates and were harvested in Mc Careys Kaufman medium or Optisol. Intraoperative lamellar separation was done by two techniques Manual and Big bubble technique. Mean follow up was 6.34 months ± 3.06 D. Mean preoperative UCVA was 1.56 ± 0.35D and preoperative BCVA was 1.56± 0.35D. The mean postoperative UCVA was 1.09 ±0.47D and BCVA was0.76± 0.54D Mean MRSE at final follow up was 0.76± 5.94D and mean cylinder was 0.41± 10.72D respectively. Among the post-operative complication loose sutures occured in 5 cases (9.25 %), 4 cases (7.40 %) had interface haze, 3 cases (5.55 %) had infiltrates which subsequently healed giving a poor visual outcome. 1 case (1.85%) had pupillary block glaucoma. 3 cases (5.55%) had double anterior chamber. 3 cases developed graft rejection during the course of follow up. 1 case (1.85 %) had graft melting. Graft edema occured in 7 cases (12.96%). clear graft was seen in 23 cases (42.59 %). Graft clarity +4 was seen in 10 cases (18. 51%). Graft clarity +3 was seen in 13 cases ((24.07%). Graft clarity +2was seen in 4 cases (7.40%).


  Discussion: Top


DALK in our study was done for both tectonic and optical purposes. It had decreased risk of endothelial rejection and intraocular complications.[8] Even corneas with low endothelial counts could be used with superior results. Vision after DALK was limited due to irregular and uneven dissection of donor corneal bed, particulate debris trapped in lamellar interface. Decreased vision occured in some cases due to mechanical folds in posterior layer over visual axis especially in cases of advanced keratoconus. The effectiveness of DALK for keratoconus patients has been extensively studied.[15] Fogla et al in a recent study of DALK in 450 eyes of 382 patients Keratoconus was the most common indication (84.8%)[10]. Yorston et al found Keratoconus was the most common indication (50 %) for transplantation in their series in a single center in Kenya with graft survival of 87.4% at 2 years for the indication compared to 64.7% for other corneal pathologies. Our case study had a similar result with keratoconus as the most common indication with 48.1%. We observed that DALK was less effective in macular corneal dystrophy due to involvement of deeper layers of stroma. In some studies, visual acuity of 20/40 or better has been seen in 77.8-92.3% of keratoconus patient after DALK. A similar study done on 80 eyes 68 consecutive patients done by bruce et al with a mean follow up of 21.2 months BCVA at last follow up was 6/6 or better in 24.7%, 6/9 in 69.9%, 6/12 or better in 84.9% of eyes the mean postoperative cylinder was 3.31 ± 2.59 D and mean spherical equivalent was -2.54±3.61 D.[21]. Feizi et al observed astigmatism > 4 D in 34.4% of patients undergoing DALK.[22] In our study the BCVA at last follow up was 0.76± 0.54D, Mean MRSE at final follow up was 0.76± 5.94D and mean cylinder was 0.41±10.72D. BCVA in our study was 6/9 or better in 14.8%, 6/12 or better in 33.3%, 6/36 or better in 64.8%. In intraoperative events microperforation rates were higher with manual layer by layer dissection and lower with Anwar's big bubble technique[3]. Peripheral folds and central Descemet membrane folds occured in some cases due to mismatch between donor button and recipient bed size and oversizing of donor button by 0.25-0.50mm was recommended to prevent such complications.[7] Double anterior chamber occured in 3 cases and these were due to microperforation of DM. A shallow pseudo anterior chamber may be self-limited and resolves after a few days. Interface haze from vascularisation and opacification occured in 4 cases and lead to complications like suture loosening and appositional problems[14] Some cases had evidence of infiltrates occuring at potential dead space at interface. The most common infection was fungal infection as detected by KOH and gram staining. The study by Bruce et al showed rejection episodes in 9.6% of cases[21]. In our study Graft rejection developed in 3 cases. Although DALK carries no risk of endothelial risk but there persist chances of sub epithelial and stromal rejection.[13] These can lead to complication like suture abscess and graft vascularisation leading to poor visual outcome and graft failure, stromal rejection is usually mild and can be attenuated quickly by topical steroid.[12] As rejection is relatively rare and mild in DALK, it requires a shorter postoperative steroid regimen, which reducing the risk of complications such as cataract and glaucoma.[11] In addition, the suture can be removed earlier, which beneficial to postoperative rehabilitation[16]. In our institute we use steroids post operatively for at least - 3 months which in some cases causes a rise in IOP.


  Conclusion: Top


In central India where high-quality grafts are less frequently available DALK is a preferable choice for patients whose risk of rejection may be higher or where optimal postoperative care is not available due to lack of regular follow up. DALK appears to be an acceptable alternative to Penetrating keratoplasty in stromal corneal diseases because it retains the advantages of both lamellar and full-thickness corneal transplantation.



 
  References Top

1.
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2.
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8.
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9.
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10.
Fogla R, Padmanabhan. Results of deep lamellar keratoplastyusing the big-bubble technique in patients with keratoconus. Am J Ophthalmol. 2006 Feb;141(2):254e259.  Back to cited text no. 10
    
11.
Price FW, Whitson WE, Collins KS, et al. Five-year cornealgraft survival: a large, single-centre patient cohort. Arch Ophthalmol. 1993;111:799e805.  Back to cited text no. 11
    
12.
Thompson RW, Price OM, Bowers PJ, Price Jr FW. Long termgraft survival after penetrating keratoplasty. Ophthalmology. 2003;110:1396e1402.  Back to cited text no. 12
    
13.
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14.
Parthasarathy A, Por YM, Tan DT. Use of a ‘small-bubbletechnique’ to increase the success of Anwar's ‘big-bubble technique’ for deep lamellar keratoplasty with complete baring of Descemet's membrane. Br J Ophthalmol. 2007 Oct;91(10):1369e1373.  Back to cited text no. 14
    
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Shimmura S, Tsubota K. Deep anterior lamellar keratoplasty. Curr Opin Ophthalmol. 2006 Aug;17(4):349e355.  Back to cited text no. 15
    
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Marchini G, Mastropasqua L, Pedrotti E, Nubile M,Ciancaglini M, Sbabo A. Deep lamellar keratoplasty by intracorneal dissection: a prospective clinical and confocal microscopic study. Ophthalmology. 2006 Aug;113(8):1289e1300.  Back to cited text no. 16
    
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Trimarchi F, Poppi E, Klersy C, Piacentini C. Deep lamellar keratoplasty. Ophthalmologica. 2001 Nov-Dec;215(6):389-93.  Back to cited text no. 18
    
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Kirkness CM, Ficker LA, Steele AD, Rice NS. The success of penetrating keratoplasty for keratoconus. Eye (Lond). 1990;4 (Pt 5):673-88.  Back to cited text no. 19
    
20.
Rumelt S, Blum-Hareuveni T, Bersudsky V, Development and progression of cataract in patients required repeated corneal transplantation. Eye (Lond). 2003 Nov;17(9):1025-31  Back to cited text no. 20
    
21.
Bruce A. Noble, FRCS, FRCOphth, Ashish Agrawal, MS(Ophth), et al. Deep Anterior Lamellar Keratoplasty (DALK) Visual Outcome and Complications for a Heterogeneous Group of Corneal Pathologies. Cornea, 2007; 26(1):59  Back to cited text no. 21
    
22.
Feizi S, Javadi MA, Rastegarpour A. Visual acuity and refraction after deep anterior lamellar keratoplasty with and without successful big- bubble formation. Cornea 2010;29:1252-55.  Back to cited text no. 22
    




 

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