Singapore National Eye Centre, Singapore.
Cornea. 2011 Apr;30(4):454-9. doi: 10.1097/ICO.0b013e3181f0b1f3.
Deep anterior lamellar keratoplasty (DALK) using Anwar's big-bubble technique is contraindicated in cases of previous hydrops because of the risk of Descemet membrane (DM) rupture at the hydrops scar. Improved manual lamellar dissection techniques down to the deepest stromal layers now enable manual DALK surgery for previous hydrops with the possibility of obtaining good vision, as an alternative to conventional penetrating keratoplasty.
Two retrospective case reports of manual DALK in patients with previous hydrops.
A 12-year-old boy, with keratoconus and resolved hydrops in his left eye with deep stromal scarring, underwent bilateral manual DALK without baring of the DM. An intraoperative microperforation occurred in his left eye and was managed by intracameral injection of air to seal the perforation. Eleven months after his right DALK and 10 months after his left DALK, his right best spectacle-corrected visual acuity (BSCVA) was 20/20, and his left BSCVA was 20/25. The right cornea was clear, whereas the left cornea had minimal residual deep stromal scarring. Endothelial cell count by specular microscopy was 2611 cells per square millimeter in the right eye and 2193 cells per square millimeter in the left eye. A 28-year-old man, with keratoconus and resolved hydrops in his right eye with deep stromal scarring, underwent right manual DALK without baring of the DM. Nine months postoperatively, his right BSCVA was 20/30, and the graft was clear. Endothelial cell count by specular microscopy was 3148 cells per square millimeter in the right eye.
DALK can be performed in patients with previous hydrops. A controlled deep manual dissection technique without baring the DM is advocated. Good final BSCVA can be achieved despite leaving a thin residual layer of the stroma unexcised.
采用 Anwar 大泡技术的深层前板层角膜移植术（DALK）在先前存在水肿的情况下是禁忌的，因为在水肿疤痕处存在 Descemet 膜（DM）破裂的风险。现在，改良的手动板层分离技术可以深入到最深处的基质层，为先前存在水肿的患者进行手动 DALK 手术，有可能获得良好的视力，作为传统穿透性角膜移植术的替代方法。
回顾性报告 2 例先前存在水肿的患者接受手动 DALK 的病例。
一名 12 岁男孩，左眼圆锥角膜伴水肿消退，深层基质瘢痕形成，行双侧手动 DALK，未暴露 DM。左眼术中发生微穿孔，采用房内注气封闭穿孔。右眼 DALK 后 11 个月，左眼 DALK 后 10 个月，右眼最佳矫正视力（BSCVA）为 20/20，左眼 BSCVA 为 20/25。右眼角膜透明，左眼角膜残留少量深层基质瘢痕。右眼角膜内皮细胞计数为 2611 个细胞/平方毫米，左眼为 2193 个细胞/平方毫米。一名 28 岁男性，右眼圆锥角膜伴水肿消退，深层基质瘢痕形成，行右眼手动 DALK，未暴露 DM。术后 9 个月，右眼 BSCVA 为 20/30，移植物透明。右眼角膜内皮细胞计数为 3148 个细胞/平方毫米。
DALK 可在先前存在水肿的患者中进行。主张采用不暴露 DM 的控制性深层手动分离技术。尽管未切除的基质残留层较薄，但仍可获得良好的最终 BSCVA。
