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. 1999 Mar;83(3):327–333. doi: 10.1136/bjo.83.3.327

A new surgical technique for deep stromal, anterior lamellar keratoplasty

G Melles 1, F Lander 1, F Rietveld 1, L Remeijer 1, W Beekhuis 1, P Binder 1
PMCID: PMC1722959  PMID: 10365042

Abstract

AIMS—To describe a new surgical technique for deep stromal anterior lamellar keratoplasty.
METHODS—In eye bank eyes and sighted human eyes, aqueous was exchanged by air, to visualise the posterior corneal surface−that is, the "air to endothelium" interface. Through a 5.0 mm scleral incision, a deep stromal pocket was created across the cornea, using the air to endothelium interface as a reference plane for dissection depth. The pocket was filled with viscoelastic, and an anterior corneal lamella was excised. A full thickness donor button was sutured into the recipient bed after stripping its Descemet's membrane.
RESULTS—In 25 consecutive human eye bank eyes, a 12% microperforation rate was found. Corneal dissection depth averaged 95.4% (SD 2.7%). Six patient eyes had uneventful surgeries; in a seventh eye, perforation of the lamellar bed occurred. All transplants cleared. Central pachymetry ranged from 0.62 to 0.73 mm.
CONCLUSION—With this technique a deep stromal anterior lamellar keratoplasty can be performed with the donor to recipient interface just anterior to the posterior corneal surface. The technique has the advantage that the dissection can be completed in the event of inadvertent microperforation, or that the procedure can be aborted to perform a planned penetrating keratoplasty.

 Keywords: corneal surgery; lamellar keratoplasty; air; optical interface

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Figure 1  .

Figure 1  

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Diagrammatic representation of the deep, anterior lamellar keratoplasty technique. (A) After dissection of a deep stromal pocket through a scleral incision. (B and C) Viscoelastic is injected into the pocket, and an anterior corneal lamella is trephinated from the recipient cornea. (D) After stripping Descemet's membrane, a full thickness donor corneal button is sutured into the recipient stromal bed. Compare with Figures 2A-C and 3A-F.

Figure 2  .

Figure 2  

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Demonstration of the surgical technique in a human eye bank eye. (A) The anterior chamber has been filled with air. In between the blade tip and the air to endothelial interface light reflex, a dark band (arrowheads) is visible. (B) Because the dark band reflects unincised posterior corneal tissue, the dark band decreases in width when the blade is advanced into the deeper stromal layers. (C) When the blade appears to touch the air to endothelium interface, a stromal dissection level just anterior to the posterior corneal surface is reached.

Figure 3  .

Figure 3  

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Demonstration of the surgical technique in a human eye bank eye. (A) The pocket is dissected first across the vertical meridian, and then extended sideways up to the limbus over 360°, with the same spatula. Note that the anterior chamber is completely filled with air, and that the dissection depth can be monitored by the width of the dark band (arrowhead) in between the spatula and the air to endothelium light reflex. Note also the wrinkling of the posterior corneal tissue (arrow). (B) After most air has been removed from the anterior chamber, the stromal pocket is filled with viscoelastic. Note the step ladder configuration of the relaxed posterior corneal tissue (arrow) which is pushed downward. (C) After trephination with a Hessburg-Barron trephine (D) an anterior corneal lamella is excised. Note the smooth recipient bed (asterisk) with some residual posterior stroma overlying the pupillary border (arrowheads). Pupillary dilatation was not intended as a part of the procedure. (E) After stripping Descemet's membrane, a "full thickness" donor button (arrow) is placed onto the recipient bed, and the donor and recipient corneal surfaces are marked with an eight incision radial keratotomy marker. (F) The donor button sutured in place with two running sutures. Pupillary dilatation was not an intended part of the procedure.            

Figure 4  .

Figure 4  

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Light microscopy of a deep lamellar dissection through a scleral incision in a human eye bank eye. (A) A deep stromal dissection level (arrowheads) is seen (98% corneal depth). (B) Few stromal lamellae (arrows) are visible between the stromal dissection and Descemet's membrane; the dotted line indicates the junction of the stroma and Descemet's membrane (haematoxylin and eosin, original magnification ×35 and ×450).

Figure 5  .

Figure 5  

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Slit lamp photograph 6 months (patient eye 1) after deep, anterior lamellar keratoplasty. A clear lamellar corneal transplant is visible, with a deep stromal, donor to recipient interface (arrow).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

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