Department of Ophthalmology, Case Western Reserve University, Cleveland, Ohio, USA.
Ophthalmology. 2011 Jan;118(1):209-18. doi: 10.1016/j.ophtha.2010.11.002.
To review the published literature on deep anterior lamellar keratoplasty (DALK) to compare DALK with penetrating keratoplasty (PK) for the outcomes of best spectacle-corrected visual acuity (BSCVA), refractive error, immune graft rejection, and graft survival.
Searches of the peer-reviewed literature were conducted in the PubMed and the Cochrane Library databases. The searches were limited to citations starting in 1997, and the most recent search was in May 2009. The searches yielded 1024 citations in English-language journals. The abstracts of these articles were reviewed, and 162 articles were selected for possible clinical relevance, of which 55 were determined to be relevant to the assessment objective.
Eleven DALK/PK comparative studies (level II and level III evidence) were identified that compared the results of DALK and PK procedures directly; they included 481 DALK eyes and 501 PK eyes. Of those studies reporting vision and refractive data, there was no significant difference in BSCVA between the 2 groups in 9 of the studies. There was no significant difference in spheroequivalent refraction in 6 of the studies, nor was there a significant difference in postoperative astigmatism in 9 of the studies, although the range of astigmatism was often large for both groups. Endothelial cell density (ECD) stabilized within 6 months after surgery in DALK eyes. Endothelial cell density values were higher in the DALK groups in all studies at study completion, and, in general, the ECD differences between DALK and PK groups were significant at all time points at 6 months or longer after surgery for all of the studies reporting data.
On the basis of level II evidence in 1 study and level III evidence in 10 studies, DALK is equivalent to PK for the outcome measure of BSCVA, particularly if the surgical technique yields minimal residual host stromal thickness. There is no advantage to DALK for refractive error outcomes. Although improved graft survival in DALK has yet to be demonstrated, postoperative data indicate that DALK is superior to PK for preservation of ECD. Endothelial immune graft rejection cannot occur after DALK, which may simplify long-term management of DALK eyes compared with PK eyes. As an extraocular procedure, DALK has important theoretic safety advantages, and it is a good option for visual rehabilitation of corneal disease in patients whose endothelium is not compromised.
回顾已发表的关于深板层角膜内皮移植术（DALK）的文献，比较 DALK 与穿透性角膜移植术（PK）在最佳矫正视力（BSCVA）、屈光不正、免疫移植物排斥和移植物存活率方面的结果。
在 PubMed 和 Cochrane 图书馆数据库中进行了同行评议文献检索。检索范围限于 1997 年开始的引文，最近的一次检索是在 2009 年 5 月。英文期刊的检索结果为 1024 条引文。对这些文章的摘要进行了回顾，其中 162 篇文章被认为与临床相关，其中 55 篇被认为与评估目的相关。
共确定了 11 项 DALK/PK 对比研究（Ⅱ级和Ⅲ级证据），这些研究直接比较了 DALK 和 PK 手术的结果；其中包括 481 只 DALK 眼和 501 只 PK 眼。在报告视力和屈光数据的研究中，有 9 项研究显示两组间 BSCVA 无显著差异，6 项研究显示球镜等效折射无显著差异，9 项研究显示术后散光无显著差异，尽管两组散光范围通常都较大。DALK 术后 6 个月内内皮细胞密度（ECD）稳定。所有研究在研究结束时，DALK 组的 ECD 值均高于 PK 组，一般来说，在所有报道数据的研究中，在手术后 6 个月或更长时间的所有时间点，DALK 和 PK 组之间的 ECD 差异均有统计学意义。
基于 1 项研究的Ⅱ级证据和 10 项研究的Ⅲ级证据，DALK 在 BSCVA 这一结果测量指标上与 PK 相当，特别是如果手术技术产生的最小残余宿主基质厚度。DALK 对于屈光不正结果没有优势。尽管 DALK 改善移植物存活率尚未得到证实，但术后数据表明，DALK 在保存内皮细胞密度方面优于 PK。DALK 后不会发生内皮免疫移植物排斥，这可能使 DALK 眼的长期管理比 PK 眼简单。作为一种眼外手术，DALK 具有重要的理论安全性优势，是那些内皮不受损害的角膜疾病患者视力康复的一个很好的选择。
