Keratoplasty and its types explained

1. KERATOPLASTY
Dr. Karan Bhatia
Fellow
MM Joshi Eye Institute

2. Introduction
The history of "tissue transplantation" starts from Adam and
Eve in Eden. Throughout history, however, the eye, as the
avenue to the Sun God, has symbolized virtue and wisdom,
with blindness as a penalty for impiety and the stigma of
sexual shame. Blind people were generally regarded as social
outcasts, for whom treatment of any sort represented a
tampering with God's proper judgment. In myths and
folklore, although occasionally the damaged eye was
replaced by the fresh one, the eye is more usually replaced
by its symbolic equivalent of wisdom or second sight.

3. Keratoplasty – Definition
Corneal transplantation or grafting
is
an operation
in which
abnormal corneal host tissue
is
replaced by
healthy donor cornea

4. Types of Keratoplasty
1. Full thickness or Penetrating keratoplasty
2. Partial thickness or Lamellar keratoplasty
a) Superficial lamellar keratoplasty
b) Deep lamellar endothelial keratoplasty (DLEK)
3. Rotational keratoplasty (Autograft)

5. Penetrating
Keratoplasty

6. HISTORY
Frenchman named GP De Quengsy - idea of
replacement of a diseased cornea originated in the
eighteenth century
Kissam in 1844 -first attempt at keratoplasty in
a human being
The first successful penetrating keratoplasty
was done by Zirm in 1906, where the graft
remained clear for 18 months.

7. Indications
Optical
◦ Most common indication
◦ To improve the vision
Tectonic
◦ To preserve the corneal integrity
Therapeutic
◦ Remove the infected cornea unresponsive to Rx
Cosmetic
◦ To improve the appearance of eye
◦ Very rare indication

8. Clinical Examples
Healed corneal scars
Pseudophakic or aphakic bullous keratoplasty
Keratoconus
Corneal degenerations
Corneal dystrophies
Regrafting
Infectious keratitis ( herpes )
Congenital opacities
Chemical burns

9. Points to remember
Penetrating keratoplasty involves a significant amount of
postoperative care.
Important to perform a careful pre-operative evaluation and
thoroughly discuss with patients the surgery, visual
expectation, possible complications, and, in particular, the
long process of postoperative care.
The recipient must be prepared for lifelong management
of the eye.

10. PROGNOSIS
Gr I Excellent Prognosis
◦ Keratoconus
◦ Traumatic leucoma
◦ Lattice and granular dystrophy
◦ Superficial stromal scars

11. PROGNOSIS (contd.)
Gr II Good Prognosis
◦ Small vascularized scars
◦ Bullous keratopathy
◦ Fuchs' dystrophy
◦ Failed grafts from group I which have not been
vascularized
◦ Macular stromal dystrophy
◦ Interstitial keratitis

12. PROGNOSIS (contd.)
Gr III Fair Prognosis
◦ Moderately vascularized cornea
◦ Failed Gr II grafts
◦ Active stromal herpes simplex keratitis
◦ Congenital hereditary endothelial dystrophy
◦ Scars following bacterial corneal ulcers

13. PROGNOSIS (contd.)
Gr IV Guarded Prognosis
◦ Mild dry eye
◦ Active fungal keratitis
◦ Failed or rejected Gr I III grafts
◦ Corneal staphyloma
◦ Epithelial downgrowth
◦ Corneal blood staining
◦ Congenital glaucoma
◦ Most pediatric keratoplasties

14. PROGNOSIS (contd.)
Gr V poor prognosis
◦ Severe dry eye
◦ Steven-johnson syndrome
◦ Chemical burns

15. Pre-operative evaluation
1. Evaluation of visual potential.
2. Ocular surface abnormality – a variety of ocular surface diseases
must be recognized and treated prior to penetrating keratoplasty.
a. Rosacea
b. Dry eyes
c. Blepharitis
d. Trichiasis
e. Exposure keratopathy
f. Ectropion
g. Entropion.
3. Intraocular pressure (IOP) – must be controlled adequately prior to
surgery.

16. 4. Ocular inflammation – must be recognized and treated
5. Prior corneal diseases and vascularization –
◦ History of herpetic keratitis significantly reduces the chance of graft success,
as a result of several factors –
i. Recurrent disease in the graft
ii. Vascularization
iii. Trabeculitis with ↑ IOP
iv. Persistent inflammation that causes rejection.
6. Peripheral corneal melting – such as that associated with rheumatoid
arthritis, may significantly affect the surgical outcome of penetrating
keratoplasty and thus must be treated adequately prior to the surgery.
Corneal surgery in these eyes can be technically difficult. Surgical
complications include irregular astigmatism because of peripheral
ectasia and recurrent corneal thinning.
Pre-operative evaluation
(contd…)

17. Pre-operatively
Intravenous mannitol
Or
Mechanical ocular decompression (Honan balloon).
Patients who undergo a simple penetrating keratoplasty
have miotics placed preoperatively to protect the lens
during surgery.

18. Anticipate Suprachoroidal
haemorrhage
Most feared ophthalmic surgical complication.
0.45% to 1.08% of cases.
Risk much higher in eyes that have under.
Prevention –
1.Anticoagulant therapy should be stopped when feasible.
2.Best possible control of BP, tachycardia, and anxiety.
3.Intraocular pressure should be reduced preoperatively
4.Eye entered slowly to avoid the sudden release of aqueous and pressure drop that
might lead to rupture of fragile choroidal vessels.
5.For high-risk patients – consider GA.
The eye should not be left open any longer than necessary.
This shortened time is achieved by performing ahead of time steps such as donor
button preparation and vitrectomy set-up, and by prethreading sutured-in
intraocular lens implants if their use is anticipated. It is important to know the plan
and not to dawdle.

19. Anticipate Suprachoroidal
haemorrhage (Contd…)
In the event of any evidence of impending choroidal hemorrhage, such
as –
appearance of a dark choroidal detachment
forward movement of intraocular contents
patient c/o acute severe ocular pain
A closed eye should be established as fast as one can safely
sew.
If intraocular contents cannot be repositioned and an
anterior chamber established  sclerotomies.

20. SURGICAL TECHNIQUES
Anaesthesia
◦Peribulbar block

21. A. Determination of graft size
Done
◦ Pre-operatively with a variable slit beam
◦ Operatively using by trial placement of trephines with
different diameters or by measurement with a calliper
Ideal size – 7.5 mm
Grafts of diameter > 8.5 mm  more prone to –
◦ Post-operative anterior synechiae formation
◦ Vascularization
◦ ↑ IOP
Grafts of diameter < 7.5 mm  high Astigmatism.

22. B. Excision of Donor Cornea
Should always precede that of host
cornea.
 Prepared by trephining a
previously excised corneoscleral
button, endothelial side up in a
concave Teflon block (Endothelium
to epithelium) –
Hand-held trephine
Universal punch
Katena trephine blade attached to
a gravity corneal punch ( Fig.)

23. Donor can also be cut from
Epithelium to endothelium with
Hanna artificial anterior chamber.
(Has theoretical advantage that
both the donor and recipient are
cut in the same fashion with the
same blade  reduces donor-
recipient disparity and potentially
reduces astigmatism.)

24. Donor button  about 0.25 mm larger in diameter, than the planned
diameter of host opening (to facilitate water tight closure, minimize
post-operative flattening and ↓post-operative glaucoma).
Hyperopic eyes  a larger (0.5 mm) donor.
Keratoconus  a same size or smaller (0.25 mm) donor button.

25. C. Trephining of Recipient
Button
Globe should be well fixed
Cornea is blotted dry
If epithelium is loose and edematous it is removed with a cellulose
sponge
A corneal trephine of appropriate size is selected so as to encompass
whole or most of the diseased portion

26. Trephining of Recipient Button
In most cases a trephine of 7.5 to 8.5 mm size is
required.
The trephine is placed vertically over the cornea
Proper centering of trephine on the recipient cornea
is a very critical step
The trephine is then given rotating movements,
ensuring to apply equal pressure over the cornea
Approximately 80 percent depth of the cornea is
made.

27. Motorized Trephines
'Microkeratrome' allows for variation of rotation
velocity
Advantages
◦ Rapid braking within a tenth of a second
◦ Causes less stromal disruption and a smoother
interface

28. Trephining

29. Trephining

30. Trephining of Recipient Button
HANNA’s suction
trephine
A C is filled with
viscoelastic &
trephination performed

31. Trephining of Recipient Button
Excision of corneal
button using
corneoscleral scissors

32. Chamber Entry and Corneal
Button Removal
Anterior chamber may be entered using the trephine
◦ leads to a very perpendicular cut and easy removal of
host cornea
◦ Chances of iris and lens injury are high
Most of the surgeons prefer to make a controlled entry
into anterior chamber with a knife
◦ The chamber is entered with a sharp blade (B.P.No.ll/ 15⁰ lancetip
knife) inserted vertically avoiding the iris
◦ The cut is extended to 3 to 4 mm to allow the insertion of the corneal
scissors
◦ The corneal button is removed with curved corneal scissors

33. Chamber Entry and Corneal Button
Removal

34. Management of the Lens
If cataract is present it should be removed with ECCE
technique (Triple Procedure = PK + ECCE + IOL)
Preferably early cataract should also be removed because it
is bound to progress rapidly after keratoplasty.

35. Management of Vitreous
An intact vitreous face should always be preserved
If vitreous is present in front of iris then it can be removed with
cellulose sponges and Vannas scissors
When available, application of mechanized vitrectomy technique is
preferred.

36. IOL Insertion
IOL can be inserted if there is good potential for useful vision
If PC is not intact; iris fixated or scleral fixated IOL can be implanted.

37. Graft Placement and Chamber
Maintenance
Next step is to place the donor cornea onto the recipient bed
Viscoelastic material is placed over the iris and anterior lens capsule to
keep the iris and lens back and avoid their coming in contact with
endothelium

38. Suturing the Corneal Button
Suturing is the most crucial step in keratoplasty
First four sutures known as the cardinal sutures are
most crucial in orienting the graft evenly in the bed
The first suture is placed at 12 o'clock position
followed by a suture at 6 o'clock
Two sutures are then placed at 3 and 9 o'clock
positions, respectively

39. Tension lines forming a square
after 4 cardinal sutures

40. Suturing the Corneal Button
Subsequent suturing consists of placement of 12 or
more interrupted sutures, 4 or 8 interrupted and a
running suture, or a double running suture with
removal of initial 4 sutures
10-0 NYLON suture should be used
Each bite is approximately 1.0 mm long in the
donor and 1.5 mm long on the recipient side

41. Interrupted suturing technique

42. Continuous suturing technique

43. Suturing the Corneal Button
Interrupted sutures
Advantages
In children
Visualized corneas
Cornea with uneven thickness
Cornea with localized areas of inflammation
Less difficulty in placement or removal
Disadvantages
More inflammation
More vascularization

44. Suturing the Corneal Button
Continuous suture
Advantages
Less inflammation
Better wound healing
Even tension
Disadvantages
Difficult technique
Can not be selectively removed

45. Final evaluation
Suture ends are trimmed and knots are tied
A C is deepened with BSS & wound margins and checked for any leakage

47. Post-operative Managment
1. Systemic Antibiotics
 Tab. Ciprofloxacin 500 mg or 750 mg BD x 5 days
2. Local Antibiotic eye drops
 0.5 % Moxifloxacin / 0.3% Ofloxacin
 Fortified antibiotics like FF Tobramycin 1.3 % or FF Cefazolin 5 % - when
PK done for uncontrolled infectious keratitis (30 mins – 4 hourly)
(Tapered over 2-3 week period)
 In fungal Keratitis – 5 % Natamycin drops.
 Herpetic Keratitis – Oral Acyclovir 400 mg 5 times/day x 1-3 weeks
(decreased to maintainence dose 400 mg BD x 6-12 months).

48. 3. Corticosteroids
a) Topical –
 1 % Prednisolone acetate or 0.1 % Dexamethasone sodium phosphate 4-
6 times/day – tapered over several months.
 Used 1-2 hourly in –
 High risk keratoplasty
 High post-operative Astigmatism
 Increased corneal thickness
b) Systemic –
 Tab. Prednisolone acetate 1 mg/kg/day started 1-2 days before surgery
and then tapered over 2-3 weeks in high risk keratoplasties.
Post-operative Management
(contd…)

49. 3. Anti-glaucoma medication –
 Timolol maleate 0.5 % BD in cases of –
 Pre-existing glaucoma
 Penetrating Keratoplasty combined with
 Cataract surgery
 Lysis of synechiae / Anterior segment reconstruction
 Use of large amounts of hyaluronate
Post-operative Management
(contd…)

50. 5. Cycloplegics
 Short acting agents such as tropicamide 1% or cyclopentolate 1% may be
given for early post-operative pain and inflammation control.
 Wide dilatation of the pupil in cases of posterior chamber IOL may
increase the risk of formation of synechiae to the posterior capsule and
capture of the edge of the lens with iris.
 Wide dilatation should also be avoided in cases where large grafts have
been used as this may cause crowding at the angle and adherence to the
posterior edge of the wound.
6. Lubricants
 Preservative free lubricants BD to QID.
Post-operative Management
(contd…)

51. Complications
Early
Persistent epithelial defects
Irritation with protruding sutures
Papillary hypertrophy
Uveitis
Glaucoma
Wound leak
Flat A C
infection

52. Complications
Late
Astigmatism
Graft rejection
Epithelial
Sub-epithelial
Endothelial
Retrocorneal membrane
Cystoid macular edema

53. Complications
Cloudy graft
due to
endothelial
failure

54. Complications
Linear epithelial
opacity in
epithelial
rejection

55. Complications
Sub epithelial
rejection

56. Complications
Keratic
precipitates
after
endothelial
rejection

57. Complications
Protruded suture

58. Complications
Papillary
hyperplasia

59. Lamellar
Keratoplasty

60. INTRODUCTION
For over hundred years Penetrating keratoplasty has been the
standard care for corneal diseases
PKP involves replacing a full thickness of diseased recipient’s cornea
with that of a healthy donor cornea secured into place with 32,16 or
8 sutures
The procedure is widely accepted as it requires familiar surgical
skills and instrumentation
Claesson et al in their study of 520 grafts at 2 years after PK showed
a likelihood of obtaining visual acuity of 20/40 (6/12)

61. Why
there is
need for
an alternative to
PKP?????

62. Because …..
PKP induced astigmatism in range of 3 to 7
diopters
Decline in endothelial cell count leading to graft
failure
Allograft rejection and endothelial decompensation
were the major concerns

63. LAMELLAR KERATOPLASTY
Involves a partial thickness of the cornea that is
transplanted to selectively replace only the diseased
portion leaving the rest of the healthy cornea of the
patient undisturbed.
Less invasive procedure but involves finer surgical skill and
more refined instrumentation.

64. History
In 1824 Reisinger performed the first animal graft and coined the
term ‘Keratoplasty’.
The history of lamellar keratoplasty covers more than 100 years.
The first successful lamellar keratoplasty was performed by Arthur
Von Hippel at the end of 19th century.
Jose Barraquer was the first to perform posterior lamellar
keratoplasty PLK in 1950.

65. Anatomy

66. Layers Thickness (in µm) Composition
Epithelium (Ep) 50
Stratified Squamous
Epithelium
Bowman's Membrane
(BM)
8-14
Compact layer of
unorganised collagen
fibres
Stroma (SP) 500
Orderly arrangement of
collagen lamellae with
keratocytes
Descemet's Membrane
(DM)
10-12
Consists of basement
membrane materials
Endothelium (En) 5
single layer of simple
squamous epithelium

67. Stroma and Descemet's membrane

68. LAMELLAR KERATOPLASTY
Anterior lamellar Posterior lamellar
Superficial ALK(SALK) Mid ALK(MALK) Deep ALK(DALK)
Deep Lamellar Endothelial Descemet’s stripping Automated
keratoplasty (DELK) endothelial keratoplasty (DSAEK)

69. Based on type
Optical Tectonic Therapeutic Cosmetic

70. Anterior Lamellar Keratoplasty (ALK)
Removal and replacement of deformed or diseased anterior corneal
tissue ( epithelium, Bowman’s layer, and stroma)
Sparing the host Descemet’s membrane and endothelium
Classified into –
1.Optical
2.Tectonic

72. Indications
Indicated in corneas that have a healthy endothelium
1.Optical ALK is useful in for visual rehabilitation in patients
with
oAnterior stromal scars after infectious keratitis or trauma
oComplications after refractive surgery
oDystrophies like Reis-Buckler
oSalzmann nodular dystrophy
oLattice, Granular, Macular dystrophy

73. Indications (contd…)
2. Tectonic ALK is useful in for re-establishing structural
integrity of the cornea
 Peripheral non inflammatory thinning
 Terrin’s marginal degeneration
 Pellucid marginal degeneration
 Peripheral ulcerative autoimmune keratitis - Mooren’s ulcer.
3. Combined indications include
Keratoconus
Pellucid marginal degeneration
Iatrogenic keratoectasia after Refractive surgeries

74. Surgical technique
Anwar ‘BUBBLE’ TECHNIQUE
oThe technique involves trephining the anterior host corneal surface
with a Hessburg-Barron suction trephine to a depth of about 400 µm
HESSBURG-BARRON SUCTION
TREPHINE

75. o25-gauge disposable needle that is bent to about 45° is attached to a
5-mL syringe and the needle with the bevel facing downward is
inserted into the corneal stroma, as deep as possible, going through
the trephine cut.
oAir is then injected to create a big bubble (Anwar’s technique) that
will detach the deep stromal layers from the Descemet’s membrane.
Peripheral regions of the air bubble appear as a “whitish disc”

76. oThe stromal air injection creates emphysema that separates the
collagen lamellae and facilitates the lamellar dissection and removal
of the anterior stromal disk
oThis removal is done by crescent knife
oA side-port entry into the anterior chamber is made at the 6o’clock position,
and partial release of aqueous humour is done

77. oUsing a 30° superblade/15° lance tip, a small oblique incision is made
in the corneal stromal surface, releasing air and collapsing the big
bubble.

78. oThe space between the Descemet’s membrane and the detached
deep stroma is then filled with viscoelastic material, namely Healon ,
using a blunt cannula.
o“Golden ring” sign, namely displacement of the anterior chamber
air bubble by the intrastromal sodium hyaluronate that is injected
into the host corneal stroma during the stromal delamination and
separation of the stromal tissue from the Descemet’s membrane

79. oUtilizing a divide-and-conquer technique with corneal microscissors,
the remaining deep corneal stroma is excised to expose the smooth
surface of the Descemet’s membrane

80. Anwar ‘BIG BUBBLE’ Technique of DALK

81. Viscoelastic Dissection
Technique
oIf the big bubble does not appear after removing the anterior stromal
disk, a blunt cannula is used to inject viscoelastic, namely sodium
hyaluronate, into the deeper layers of the corneal stroma to create a
visco-bubble.
oThis technique detaches the deeper stromal layer from the Descemet’s
membrane, and the detached stroma is then excised to expose the
Descemet’s membrane.

82. Hydrodelamination Technique
oDeeper lamellar dissection is
performed with this technique.
oThe stromal fibers in the host bed
are cut with a sharp microsurgical
blade to create a depression in the
stromal bed.
oBalanced salt solution (BSS) is
then injected with a blunt 26G
needle at the bottom of the
depression

83. Hydrodelamination Technique
(contd…)
oBSS penetrates between the
fibers and swells.
oA fine spatula is then
inserted through a small
incision in the delaminated
tissue and moved fan like in
different direction to loosen
the residual stroma which is
then dissected to reach the
Descemet’s membrane.

84. Microkeratome Technique
oThe advantage of this technique over other lamellar
techniques is the relative ease of surgery and the low
incidence of interface scarring and irregular astigmatism.
oThe automated microkeratome is used to cut the donor
lenticule, as well as the corneal disc in the recipient eye.
The thickness of the cut can be adjusted in relation to the
depth of the lesion, by choosing the proper plate size (up to
450 μm).
oThis technique has advantage of a smooth central host bed
and a consistent and controlled bed diameter

85. Microkeratome Technique
(contd…)
oThe donor cornea is then trephined with a Hessburg-Barron trephine,
followed by staining of the endothelium with trypan blue.
oDescemet’s membrane and the donor endothelium are then removed
using dry cellulose sponges and forceps.
oThe donor cornea devoid of Descemet’s membrane and endothelium is
then placed within the host corneal bed and sutured in place with 16
interrupted 10-0 nylon sutures.

87. Lamellar Keratoplasty with AMADEUS Microkeratome

88. Clinical Outcomes
oThe techniques of dissection as well as surgeon's experience are main
factors in determining the rate of true Descemet’s membrane
(DM)exposure
oSarnicola et al* found the highest rate (60%) with Anwar's big-bubble
technique.
oSupplemented with viscoelastic dissection at the same session in the
case of unsuccessful air injection, this rate increased to as high as 77%
oViscodissection technique was the second most successful technique in
baring the DM, with a rate of 58%, followed by the hydrodelamination
(7%)

89. Complications
oDescemet’s membrane perforation
oPseudo anterior chamber
oFixed dilated pupil (Urrets-Zavalia syndrome)
oInterface wrinkling
oInterface vascularisation and opacifications & Graft
rejection
oInterface keratitis
oSuture-related complications reaction

90. Advantages of ALK
oExtra ocular surgery. Hence, less chances of postoperative
inflammation as well as secondary glaucoma.
oNo risk of endothelial graft rejection.
oNo need for long term steroid prophylaxis due to the
absence of inflammation and faster healing.
oRapid functional recovery of vision.
oDALK involves the complete removal of corneal stroma to
the level of Descemet's membrane. Therefore here is no or
minimal interface haze associated.
oVery good best corrected visual acuity (BCVA) is achieved
due to a rapid visual recovery and very low astigmatism.

91. Advantages of ALK (contd…)
oNo significant endothelial cell loss.
oLess astigmatism then penetrating keratoplasty.
oPenetrating Keratoplasty can be done if recurrences occur
or Descemet's membrane perforation occurs
intraoperatively.
oThe criteria for quality of donor tissue are not very
stringent and a donor cornea with suboptimal quality may
be used to perform the lamellar graft.

92. Deep Lamellar
Endothelial Keratoplasty
(DLEK)

93. Purpose
To remove
the diseased recipient endothelium
and
replace with
healthy donor corneal endothelium.
In 1998 Melles et al first described this technique

94. Advantages of DLEK over PKP
oA smooth surface topography without significant
change in endothelium
oA unchanged corneal curvature
oA healthy donor corneal endothelium
oTectonically stable globe

95. SURGICAL PROCEDURE
LARGE INCISION TECHNIQUE
Recipient Surgery
A scleral access incision is placed at superior limbal region of size 9.0 mm
PRE OPERATIVE APPEARANCE

96. SUPERIOR LIMBAL
PERITOMY

97. CLEAR CORNEAL STAB INCISION

98. VISCOELASTIC IN THE ANTERIOR CHAMBER
 Cohesive viscoelasticsc like Healon is usually preferred

99. SCLERO CORNEAL
LAMELLAR
POCKET IS MADE USING A
CRESCENT BLADE

100. STRAIGHT DEVERS
DISSECTOR
IS THEN USED TO
EXTEND
THE POCKET TO MID
PUPILLARY
REGION OF THE CORNEA

101. THEN A CURVED DEVERS
DISSECTOR
EXTENDS THE POCKET
COMPLETELY
TO THE LIMBUS FOR 360
DEGREES,
CREATING A TOTAL AREA
OF DEEP LAMELLAR
POCKET

102. THE RESECTION OF THE POSTERIOR RECIPIENT TISSUE IS
DONE WITH AN INTRASTROMAL TREPHINE (TERRY TREPHINE)

103. ONCE THE BLADE IS IN POSITION IN THE POCKET, IT IS
ROTATED ALONG THE ARC OF 9.0 MM SCLERAL INCISION

104. RESECTION OF THE
RECIPIENTS
DISK IS COMPLETED
USING
CINDY SCISSORS

105. ONCE THE POSTERIOR
RECEIPIENT DISK
HAS BEEN CUT 360
DEGREES, THE
TISSUE IS REMOVED FROM
THE EYE

106. DONOR TISSUE PREPARATION
THE DONOR CORNEOSCLERAL FLAP IS PLACED ON AN
ARTIFICIAL ANTERIOR CHAMBER WHICH IS COATED WITH
HELON ON THE ENDOTHELIAL SIDE
ARTIFICIAL ANTERIOR
CHAMBER
HEALON ON THE
ENDOTHELIUM

107. THE DONOR TISSUE IS THEN
CAPPED ONTO PLACE AND
TREPHINATION IS CARRIED OUT
TO ABOUT 60% DEPTH

108. LAMELLAR DISSECTION IS
COMPLETED
USING CRESCENT KNIFE
THE DONOR POSTERIOR
DISC IS
THEN PLACED ON A OUSLEY
SPATULA

109. THE DONOR DISC IS THEN
SLOWLY INSERTED USING
OUSLEY SPATULA

110. THE SPATULA IS THEN GENTLY REMOVED FROM
THE EYE LEAVING THE DONOR TISSUE BEHIND
SUPPORTED BY AIR BUBBLE IN ANTERIOR
CHAMBER
10-0 NYLON IS THEN USED TO CLOSE THE
SCLERAL WOUND AND PREVENT THE ESCAPE
OF DONOR TISSUE

111. A REVERSE SINSKEY HOOK
IS THEN
USED FOR ENDOTHELIAL
SIDE
POSITIONING
APPEARANCE AT THE END
OF SURGERY

112. DEEP LAMELLAR ENDOTHELIAL KERATOPLASTY
(DLEK)
V/S
PENETRATING KERATOPLASTY (PKP)

113. DLEK vs PKP

114. • DLEK procedure preserves the normal corneal topography to allow
faster visual recovery and at 6 months, the average amount of
astigmatism after DLEK surgery was 1.63 ±0.97D*
• In contrast, after standard PKP surgery, the average astigmatism is
often reported to be between 4.00 and 6.00D.
The donor endothelial cell density after replacement surgery is
one predictive factor of long-term graft survival.
• After DLEK surgery, the average endothelial cell count at 6 months
was 2,218 ±505 cells/mm2 representing only a 22% cell loss from
preoperative donor counts.
• After PKP, the cell count has been reported as 1,958 ±718
cells/mm2 which represents a 34% cell loss from preoperative
donor counts.
*Terry MA, Ousley PJ. Endothelial replacement without surface corneal incisions or sutures: topography of the
deep lamellar endothelial Keratoplasty procedure. Cornea. 2001;20:14-18.

115. • The average visual acuity after DLEK surgery at 6 months was
20/40 (6/12).
• The quality of vision after DLEK appears to be better than after PKP
due to the normal topography and absence of irregular
astigmatism
• Topography and vision after PKP are never considered fully stable
until all of the corneal sutures have been removed, sometimes
years after the original surgery.

116. Descemet’s Membrane
Stripping Automated
Endothelial Keratoplasty
(DSAEK)

117. DSAEK
It is a method of posterior lamellar keratoplasty in
which the recipient bed is prepared by stripping off
the recipient’s Descemet's membrane.
Technique was popularized by Gerrit Melles in 1999

118. Indications of DSAEK
Fuchs endothelial dystrophy (most common)
Pseudophakic/ Aphakic bullous keratopathy
Post PK endothelial graft rejection
Iridocorneal endothelial syndromes (ICE)

119. SURGICAL TECHNIQUE
RECIPIENT’S CORNEA
WOUND
CONSTRUCTION
THROUGH A 5 MM
SCLERO CORNEAL
TUNNEL

120. WITH HEALON FILLING THE ANTERIOR CHAMBER DESCEMETORHEXIS AND
REMOVAL OF DESCEMET’S MEMBRANE AS A SINGLE DISK IS CARRIED OUT USING
DEXATOME

121. DESCEMETORHEXIS IS BEGUN IN THE DISTAL POINT FROM THE ANTERIOR
CHAMBER ENTRY SITE AND CONTINUED IN CLOCKWISE FASHION

122. THE PERIPHERAL STROMA IS MADE ROUGH USING THE
DSAEK SCRUBBER TO ENHANCE DONOR DISK ATTACHMENT TO
RECIPIENT CORNEA

123. DONOR CORNEAL DISK IS FOLDED INTO A ‘TACO FOLD’ AFTER PACING A SMALL
AMOUNT OF HEALON ONTO THE ENDOTHELIAL SURFACE

124. DONOR CORNEAL DISK IS INTRODUCED INTO THE RECIPIENT ANTERIOR
CHAMBER AND WOUND IS CLOSED BY 3 INTERRUPTED NYLON SUTURES

125. THE DONOR DISK IS UNFOLDED USING AIR WHICH IS INJECTED IN A
CONTROLLED FASHION

126. DONOR DISK IS UNIFORMLY ADHERENT TO THE PATIENT’S CORNEA

127. DSAEK

128. Complications of DSAEK
oBlood in the anterior chamber
oIris prolapse
oFluid in the donor recipient interface
oMacrofolds
oDisk detachment during un folding

129. DSAEK over DALK
• Requires less manipulation of the recipient cornea and
anterior chamber.
• Lesser intra and post operative complications.
• Graft recipient interface haze is less.
• Visual recovery is relatively rapid

130. Femtosecond Laser DSAEK
• This laser is used to create flaps in LASIK and can be used to perform
keratoplasty with different shapes of stromal cut.
• The laser uses an infrared wavelength (1053nm) to deliver closely
spaced, 3 microns spots that can be focused to a preset depth to
photodisrupt the tissue within the corneal stroma.
• Femtosecond laser is used to create a dissection plane on the donor
cornea mounted on artificial anterior chamber.
• Offers a potential advantage over microkeratome with regards to better
sizing of the posterior lenticule.
•Obtains a smooth surface and precise stromal cuts

131. The incidence of Corneal blindness in India and the
world is increasing day by day.
Keratoplasty acts a solution to those needy people
helping them to carry out their daily lives is a much
better manner.
Thankyou

132. THANK YOU