Future Directions in Lamellar Corneal Transplantation

The concept of lamellar keratoplasty (LK) is that of targeted lamellar replacement of corneal tissue while retaining normal cornea. It involves replacing either anterior stroma [anterior lamellar keratoplasty (ALK)] or posterior replacement of deep stromal and endothelial layers [posterior lamellar keratoplasty (PLK) or endothelial keratoplasty]. Despite the distinct advantages of ALK surgery, penetrating keratoplasty (PK) remains the most common procedure-largely because lamellar surgery is more technically demanding and time consuming, and interface irregularity arising from manual lamellar dissection often results in suboptimal visual outcomes. Recent improvements of surgical technique and advances in instrumentation such as microkeratome-assisted lamellar transplantation have contributed to improved visual quality with LK surgery. Long-term graft survival rates and endothelial cell counts after PK continue to drop for many years after surgery, clearly showing the disadvantage of unnecessary replacement of healthy endothelium in anterior-stromal disorders. The aim of this review is to evaluate the shifting emphasis from penetrating to lamellar forms of corneal transplantation and to highlight some future directions in lamellar surgery including new techniques in both ALK and PLK and the use of microkeratomes and femtosecond lasers to enhance outcomes.

[1]  K. Tsubota,et al.  Deep Lamellar Keratoplasty (DLKP) in Keratoconus Patients Using Viscoadaptive Viscoelastics , 2005, Cornea.

[2]  A. Geerards,et al.  A Quick Surgical Technique for Deep, Anterior Lamellar Keratoplasty Using Visco-dissection , 2000, Cornea.

[3]  A. Loewenstein,et al.  Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement , 1998, The British journal of ophthalmology.

[4]  T. Wong,et al.  Changing indications for penetrating keratoplasty: a newly developed country's experience. , 1997, Australian and New Zealand journal of ophthalmology.

[5]  D. Dobrowolski,et al.  Deep Lamellar Keratoplasty for Various Corneal Lesions , 2004, European journal of ophthalmology.

[6]  A. Balestrazzi,et al.  Air-Guided Manual Deep Lamellar Keratoplasty , 2004, European journal of ophthalmology.

[7]  T. Kohnen,et al.  Corneal Trephination With the Femtosecond Laser , 2006, Cornea.

[8]  M. Terry,et al.  Deep Lamellar Endothelial Keratoplasty: Surgery in Complex Cases With Severe Preoperative Visual Loss , 2005, Cornea.

[9]  S. Jain,et al.  A new surgical technique of microkeratome-assisted deep lamellar keratoplasty with a hinged flap. , 2000, Archives of ophthalmology.

[10]  T. Wong,et al.  Penetrating keratoplasty in the Singapore National Eye Centre and donor cornea acquisition in the Singapore Eye Bank. , 1997, Annals of the Academy of Medicine, Singapore.

[11]  F. Price,et al.  Descemet's stripping with endothelial keratoplasty: comparative outcomes with microkeratome-dissected and manually dissected donor tissue. , 2006, Ophthalmology.

[12]  M. Muraine,et al.  Deep lamellar keratoplasty combined with cataract surgery. , 2002, Archives of ophthalmology.

[13]  T. H. Pettit,et al.  TECHNIQUES OF LAMELLAR KERATOPLASTY , 1988, International ophthalmology clinics.

[14]  N. M. Macindoe Lamellar grafting. , 1955, Transactions of the Ophthalmological Society of Australia.

[15]  Marianne O Price,et al.  Descemet's stripping with endothelial keratoplasty in 200 eyes: Early challenges and techniques to enhance donor adherence , 2006, Journal of cataract and refractive surgery.

[16]  Sanjay V. Patel,et al.  In Vivo Femtosecond Laser-Assisted Posterior Lamellar Keratoplasty in Rabbits , 2006, Cornea.

[17]  E. Pels,et al.  Femtosecond-laser-assisted Descemet's stripping endothelial keratoplasty. , 2007, Journal of cataract and refractive surgery.

[18]  P. Padmanabhan,et al.  Initial results of small incision deep lamellar endothelial keratoplasty (DLEK). , 2006, American journal of ophthalmology.

[19]  M. Terry,et al.  Rapid Visual Rehabilitation After Endothelial Transplants With Deep Lamellar Endothelial Keratoplasty (DLEK) , 2004, Cornea.

[20]  P. Mulder,et al.  Endothelial cell density after deep anterior lamellar keratoplasty (Melles technique). , 2004, American journal of ophthalmology.

[21]  T. Juhász,et al.  Femtosecond laser-assisted posterior lamellar keratoplasty: initial studies of surgical technique in eye bank eyes. , 2005, Ophthalmology.

[22]  C. Sheard,et al.  Deep lamellar keratoplasty on air with lyophilised tissue. , 1992, The British journal of ophthalmology.

[23]  H. Welling,et al.  Application of ultrashort laser pulses for intrastromal refractive surgery , 2000, Graefe's Archive for Clinical and Experimental Ophthalmology.

[24]  M. Terry,et al.  Small-incision deep lamellar endothelial keratoplasty (DLEK): six-month results in the first prospective clinical study. , 2005, Cornea.

[25]  F. Price,et al.  Cataract progression and treatment following posterior lamellar keratoplasty , 2004, Journal of cataract and refractive surgery.

[26]  Catey Bunce,et al.  Comparison of deep lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus. , 2002, Ophthalmology.

[27]  J. Alió,et al.  New techniques in lamellar keratoplasty. , 2002, Current opinion in ophthalmology.

[28]  M. Anwar,et al.  Fluid lamellar keratoplasty in keratoconus. , 2000, Ophthalmology.

[29]  J. Singh,et al.  Deep lamellar keratoplasty versus penetrating keratoplasty for corneal lesions. , 1999, Cornea.

[30]  R. Chuck,et al.  Microkeratome Versus Femtosecond Laser Predissection of Corneal Grafts for Anterior and Posterior Lamellar Keratoplasty , 2006, Cornea.

[31]  G. Melles,et al.  Sutureless, Posterior Lamellar Keratoplasty: A Case Report of a Modified Technique. , 2002, Cornea.

[32]  D. Durrie,et al.  Femtosecond laser versus mechanical keratome flaps in wavefront‐guided laser in situ keratomileusis: Prospective contralateral eye study , 2005, Journal of cataract and refractive surgery.

[33]  K. Tsubota,et al.  Randomized clinical trial of deep lamellar keratoplasty vs penetrating keratoplasty. , 2002, American journal of ophthalmology.

[34]  M. Anwar,et al.  Deep Lamellar Keratoplasty: Surgical Techniques for Anterior Lamellar Keratoplasty With and Without Baring of Descemet's Membrane , 2002, Cornea.

[35]  J. Kirwan,et al.  Deep lamellar keratoplasty with lyophilised tissue in the management of keratoconus , 2001, The British journal of ophthalmology.

[36]  L. Ang,et al.  Modified Automated Lamellar Therapeutic Keratoplasty for Keratoconus: A New Technique , 2006, Cornea.

[37]  Achim Langenbucher,et al.  Nonmechanical posterior lamellar keratoplasty using the femtosecond laser (femto-plak) for corneal endothelial decompensation. , 2003, American journal of ophthalmology.

[38]  R. Chuck,et al.  Femtosecond Laser Posterior Lamellar Keratoplasty: A Laboratory Model , 2005, Cornea.

[39]  Sanjay V. Patel,et al.  Corneal endothelium and postoperative outcomes 15 years after penetrating keratoplasty. , 2005, Transactions of the American Ophthalmological Society.

[40]  M. Terry,et al.  Deep lamellar endothelial keratoplasty (DLEK): pursuing the ideal goals of endothelial replacement , 2003, Eye.

[41]  I. Jiménez‐Alfaro,et al.  Therapeutic lamellar keratoplasty with an automated microkeratome. , 2001, Journal of cataract and refractive surgery.

[42]  M. Terry,et al.  In Pursuit of Emmetropia: Spherical Equivalent Refraction Results with Deep Lamellar Endothelial Keratoplasty (DLEK) , 2003, Cornea.

[43]  P. Binder,et al.  Posterior lamellar keratoplasty for a case of pseudophakic bullous keratopathy. , 1999, American journal of ophthalmology.

[44]  E. Pels,et al.  A surgical technique for posterior lamellar keratoplasty. , 1998, Cornea.

[45]  M. Terry,et al.  Deep Lamellar Endothelial Keratoplasty in the First United States Patients: Early Clinical Results , 2001, Cornea.

[46]  K. Hirano,et al.  Separation of Corneal Stroma and Descemet's Membrane During Deep Lamellar Keratoplasty , 2002, Cornea.

[47]  D. Covert,et al.  Early results of small-incision Descemet's stripping and automated endothelial keratoplasty. , 2007, Ophthalmology.

[48]  Juntaro Sugita,et al.  Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement , 1997, The British journal of ophthalmology.

[49]  A. Geerards,et al.  The future of lamellar keratoplasty. , 1999, Current opinion in ophthalmology.

[50]  R. H. Wijdh,et al.  A Technique to Excise the Descemet Membrane From a Recipient Cornea (Descemetorhexis) , 2004, Cornea.

[51]  C. Nieuwendaal,et al.  Sutureless, Posterior Lamellar Keratoplasty , 2002 .

[52]  D. Tan,et al.  Automated lamellar therapeutic keratoplasty for post-PRK corneal scarring and thinning. , 2004, American journal of ophthalmology.

[53]  E. Manche,et al.  Deep lamellar keratoplasty using viscoelastic dissection. , 1999, Archives of ophthalmology.

[54]  E. Pels,et al.  Preliminary clinical results of posterior lamellar keratoplasty through a sclerocorneal pocket incision. , 2000, Ophthalmology.