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    Lamellarkeratoplasty 2

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    dr.sirisha rampilla
    lamellar keratoplasty PPT

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    Lamellarkeratoplasty 2

    Uploaded by

    dr.sirisha rampilla
    29 views28 pages
    lamellar keratoplasty PPT

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    lamellarkeratoplasty-2

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    lamellar keratoplasty PPT

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    29 views28 pages

    Lamellarkeratoplasty 2

    Uploaded by

    dr.sirisha rampilla
    lamellar keratoplasty PPT

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 28

    DALK

    (DEEP ANTERIOR LAMELLAR KERATOPLASTY)

    Moderator- Dr.John Sarkar


    Presenter- Dr.Sirisha Rampilla
    CLASSIFICATION

    LAMELLAR KERATOPLASTY

    ANTERIOR LAMELLAR POSTERIOR LAMELLAR


    KERATOPLASTY KERATOPLASTY

    Descemet’s
    Superficial Deep stripping Descemet Deep
    anterior anterior endothelial membrane lamellar
    lamellar lamellar keratoplasty endothelial endothelial
    keratoplasty keratoplasty (DSEK) keratoplasty keratoplasty
    (SALK) (DALK) (DMEK) (DLEK)
    (DSAEK)
    Why lamellar keratoplasty??

    Loose suture can induce


    Unpredictable post op epithelial breakdown, Long post operative visual
    astigmatism ulceration, infection, recovery
    vascularisation .

    corneal wound relatively


    Dramatic shift in corneal
    fragile, with poor tectonic Increased risk of all open
    topography can occur
    strength, making eye sky procedure like RD,
    following suture removal
    susceptible to minor trauma expulsive choroidal
    resulting in irregular
    even several years following haemorrage.
    astigmatism
    surgery
    ANATOMY
    LAYERS THICKNESS(µm) COMPOSITION

    Epithelium 50 Stratified squamous

    Bowman’s membrane 8-14 Compact layer of


    unorganized collagen fiber
    Stroma 500 Orderly arranged collagen
    lamellae with keratocyte
    Dua’s layer 10-15 Consists of typ 1 collagen

    Descemet’s membrane 8-10 Consist of basement


    membrane
    Endothelium 5 Single layer of simple
    squamous epithelium
    SURGICAL ANATOMY OF STROMA
     Thickness of Collagen fibrils in Ant. 1/3 Post 2/3

    stroma- 478-500 Orientation to oblique parallel


    corneal surface
    microns arrangement Branching present Less loosely placed
    lamella interweave
     The deeper in the
    stroma the surgeon
    is, the easier it is to
    dissect between the
    lamellae
     i.e Easier to do LK,
    The deeper we go
    • ADVANTAGE • DISADVANTAGE
    I. Non-penetrating surgery I. Technically more demanding
    and time consuming
    II. Reduced risk of
    endothelial graft rejection II. Suboptimal visual acuity
    compared to PK due to
    III. Does not require good
    endothelial quality donor  Interface problems
    tissue  Lamellar dissection
    regularity
    IV. Technically achieves a
    stronger corneal wound  Residual scarring

    V. Suture related astigmatism


    is lesser
    OPTICAL ALK- FOR VISUAL
    REHABILITATION

    Congenital dermoid Post chem. scar Post trauma scar

    Healed SPKS Band keratopathy Salzmann nodule


    TECTONIC ALK- FOR RE-ESTABLISHING
    STRUCTURAL INTEGRITY OF THE CORNEA

    Pellucid marginal
    Mooren’s ulcer
    degeneration

    Terrin’s marginal degeneration


    THERAPEUTIC – TO ELIMINATE
    CORNEAL INFECTION

    MICROBIAL KERATITIS
    optical + tectonic ALK
    ANTERIOR LAMELLAR
    KERATOPLASTY
    Superficial Anterior Deep Anterior Lamellar
    Lamellar Keratoplasty (DALK)
    Keratoplasty (SALK) • corneal stroma is completely
    excised up to DM
    • anterior 30 to 50% of
    • stroma-to-DM interface
    cornea
    provides higher quality
    • stroma-to-stroma vision
    interfaces can degrade
    visual acuity over time
    Slit lamp: depth
    of stroma
    involved

    Lid and adnexa,


    tear
    film,infection/i
    Anterior Preoperative nflammation,
    segment
    OCT assessment posterior
    segment, IOP,
    general
    systemic exam

    Pachymetry
    Surgical technique
    Globe exposure

    Host cornea marking: optical axis is marked using gentian violet


    marking pen.
    Stained 8 or 12 prong radial marker used to aid in suture placement

    Sizing & trephination: size of opacity measured with measuring caliper


    Trephine is preset to requisite depth in accordance with depth of stromal
    involvement
    Partial thickness trephination of host cornea is done

    Stromal dissection types:


    1.Manual
    2. automated
    1.MANUAL DISSECTION

    • CLOSED DISSECTION-

    After desired depth trephination, stromal pocket is made with


    paufique knife at incision site

    Introduce lamellar dissector through the pocket while lifting up the


    anterior lip of the flap

    Dissection continued by gentle side to side movement and parallel to


    posterior stroma

    Smoother preparation but no direct visualisation possible


    OPEN DISSECTION

    • Here the edge of the separated anterior lamellar tissue is held retracted with the help of
    forceps during the dissection enabling direct visualization of the area of separation.

    2.AUTOMATED LAMELLAR KERATOPLASTY-


    • Microkeratome used Allows for superior smooth surface
    • Not suitable for thin & irregular corneas as in advanced keratoconus

    Indications:
    • Stromal lesions limited to anterior stromal layers
    • Moderate keratoconus
    • Post PRK haze
    IN DALK

    • Entire corneal stroma is removed baring the Descemet’s membrane .


    Adv –
    • elimination of the graft host stromal interface, scarring, irregularity
    • Various methods used to seperate DM from stroma-
    1. Air dissection- ANWAR BIG BUBBLE TECHNIQUE most commonly used
    2. Viscodissection –
    3. Hydrodelamination –saline solution is used
    • Careful manual peeling using tryphan blue for better
    visualization of DM in donor cornea
    • clevage plane should be between banded and non banded part of
    DM in recipient preparation
    • Hydrodelamination has 39% chance of perforation
    • Air dissection has 9% chance of perforation
    ANWAR BIG BUBBLE
    TECHNIQUE
    DONOR CORNEA

    • The donor tissue is prepared by


    punching an appropriate sized CS button
    with a trephine.
    • Trypan blue can be used to stain the
    endothelium to improve visualization in
    order to facilitate the removal to DM
    and endothelium from donor tissue.
    • Donor tissue is then sutured with host
    tissue using 10-0 nylon sutures in a
    contineuos or interrupted fashion.
    INTRAOP COMPLICATION
    • Descemet membrane perforation-
     Microperforation –self sealing or inject air to AC
     Large perforation from rim to rim- suture (10-0 nylon)it with donor stroma.
    If not possible convert it to PK

    • Pseudoanterior chamber-
     Due to occult break
     Due to retained visco
     Treatment-
     Shallow double chamber-self limiting, resolve in few week, long standing
    one required surgical intervention by injecting air to AC

    • Irregular lamellar bed-


     Causes astigmatism, significant interface haze
     Can be avoided by big bubble technique or automated microkeratome
    assisted anterior lamellar keratoplasty
    • Graft-host malapposition/edge irregularity-
     due to improper sizing of tissue
     Adopt hemi-automated anterior lamellar procedure in which the
    trephine is used to cut grafts of appropriate size after the donor
    automated cuts on the donor cornea and the host corneal lamellar
    dissection is performed manually.

    • Interface debris-
     due to fibers, bleeding
     Wash thoroughly after procedure
    POST OP COMPLICATION

    • Persistent epithelial defect


    • Infection: Graft infection due to various causes such as suture related,
    lid adnexal abnormalities, poor ocular surface, prolonged topical steroid,
    poor hygiene

    • Recurrence of the primary pathology- ex HSV, corneal dystrophy


    • Graft Rejection- less common
    • Graft vascularization-can be seen in ocular surface pathologies such as
    trachomatous keratopathy, chemical burns and Stevens-Johnson
    syndrome.
    RECENT ADVANCES
    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
    SUTURELESS CORNEAL
    ADHESION
    • Bioadhesive (Fibrin glue)- Kaufman et al successfully used
    fibrin glue in small series of lamellar keratoplasty

    • Photochemical keratodesmos is method of producing


    sutureless adhesion by applying a photosensitizer to wound
    surfaces followed by low energy laser irradiation. Laser
    promotes cross linkage between collagen molecules to produce
    tight seal without thermal damage
    Thank
    you

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