Sutureless superfi cial anterior lamellar keratoplasty in a patient with epithelial-stromal dystrophy

A case report of corneal epithelial-stromal dystrophy managed with microkeratomeand femtosecond laser-assisted two-stage anterior lamellar keratoplasty. Two surgical procedures were performed. In the fi rst, a corneal fl ap was created using a microkeratome. After 9 weeks, the fl ap depth was measured by optical coherence tomography and a 7.5-mm central trephination was performed to that depth. At this point, the trephined disk was removed. A similar thickness donor disk that had been obtained minutes earlier with femtosecond laser was then placed in the surgical bed. No sutures were used. Th e procedure described signifi cantly improved the patient’s visual acuity and ocular symptoms from the fi rst postoperative week. Th is technique is a good option for patients with epithelial-stromal corneal dystrophies, improving visual acuity and ocular symptom relief, with the option of transplanted disk replacement in the future in the event of dystrophy recurrence. J Emmetropia 2016; 4: 223-229 Th e corneal dystrophies are a heterogeneous hereditary, non-infl ammatory, slowly progressive, bilateral and symmetric group of pathologies1,2. Th e latest classifi cation categorizes corneal dystrophies based on the histological layer involved: epithelial and subepithelial, epithelial-stromal transforming growth factor beta-induced (TGFBI), stromal, and endothelial1. Reis-Bücklers corneal dystrophy (RBCD) is an autosomal dominant, category-1 dystrophy, characterized by the presence of keratoepithelin in immunohistochemistry studies. It belongs to the previously denominated Bowman’s dystrophies category, better known today as epithelial-stromal TGFBI dystrophies, because the area involved is not limited to the Bowman’s membrane, but also extends to the epithelium and anterior stroma1,2. Th iel-Behnke corneal dystrophy, which also belongs to the epithelial stromal TGFBI dystrophies, seems to be more frequent than RBCD, but has less visual impact, later appearance and lower rate of recurrence after surgical interventions3. However, it is very hard to diff erentiate clinically between these two conditions. Diff erences can be seen only when performing electron microscopy, which reveals curved collagen fi bres in the case of Th iel-Behnke, instead of the classic cylindrical or trapezoidal structures in RBCD3,4,5. Treatment of the epithelial-stromal TGFBI dystrophies has two main aims: improving visual acuity (VA) and relieving symptoms secondary to epithelial defects. Th erapeutic options6 include both non-surgical (ocular lubricants, ointments, contact lenses) and surgical approaches (phototherapeutic keratectomy [PTK], penetrating keratoplasty and conventional and pre-Descemet lamellar keratoplasty). Among the proposed surgical treatments for epithelial-stromal TGFBI dystrophies, anterior lamellar keratoplasty, a surgical technique that had fallen into relative disuse, has gained increasing acceptance thanks to new instrumentation and technology. Not long ago, anterior lamellar keratoplasties were done strictly by hand, which required not only an enormously experienced and skilled surgeon, but often created an irregular surgical interface, yielding suboptimal optical outcomes. Th is has been changing for some years now with the use of the microkeratome and femtosecond laser which, by producing smoother and more precise surgical beds, allow for better visual rehabilitation7-12. We describe a case of epithelial-stromal TGFBI ReisBücklers/Th iel-Behnke corneal dystrophy managed with anterior superfi cial lamellar keratoplasty without sutures that was performed in two stages using a microkeratome and femtosecond laser. Submitted: 7/9/2016 Revised: 8/4/2016 Accepted: 11/17/2016 1 CES University. Medellín, Colombia. Financial Disclosure: None of the authors has a fi nancial or proprietary interest in any product, material or method mentioned herein Corresponding Author: Luis F. Mejia Universidad CES. Ctra 25 A #1-31 of 914. Medellín, Colombia E-mail: lfmejia@une.net.co