Ospedale Privato "Villa Igea," Department of Ophthalmology, Forlì, Italy; Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.
Ospedale Privato "Villa Igea," Department of Ophthalmology, Forlì, Italy; Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy; Ospedale "SS. Giovanni e Paolo," Department of Ophthalmology, Venezia, Italy.
Ophthalmology. 2017 Jul;124(7):1072-1080. doi: 10.1016/j.ophtha.2017.02.011. Epub 2017 Mar 20.
To evaluate the outcomes of a 9-mm deep anterior lamellar keratoplasty (DALK) with removal of the deep stroma limited to the central 6-mm optical zone.
Prospective, noncomparative, interventional case series.
A total of 80 consecutive keratoconic eyes without deep stromal scarring, with at least 1 postoperative examination 1 month after complete suture removal.
A standardized DALK was performed, including (1) deep trephination of the recipient bed 450 to 550 μm in depth and 9 mm in diameter; (2) pneumatic dissection; (3) debulking of approximately 80% of the anterior stroma; (4) removal of the deep stroma (bubble roof) from a central 6-mm optical zone; and (5) transplantation of a 9-mm anterior corneal lamella cut by microkeratome-assisted dissection (400-μm head) and sutured with a double running 10-0 nylon suture.
Success rate and type of pneumatic dissection obtained; best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), and topographic astigmatism (TA), central corneal thickness (CCT) and endothelial cell density 12 months postoperatively; and intraoperative and postoperative complications.
Pneumatic dissection created a "big bubble" in 67 of 80 eyes (83.7%), all of them but 1 (1.5%) being of type 1 according to the classification by Dua et al. After complete suture removal, BSCVA averaged 0.09±0.72 logarithm of the minimum angle of resolution (logMAR) and was ≥20/20 in 28 eyes (35%), ≥20/25 in 54 eyes (67.5%), and ≥20/40 in 76 eyes (95%); RA averaged 3.10±1.30 diopters (D), with 73 eyes (91%) within 4.5 D and none above 6 D; regular TA was detected in 72 eyes (90%); mean CCT was 492±62.10 μm; postoperative endothelial cell density averaged 2026±397cells/mm with a mean cell loss of 11.2%. Intraoperative complications included loss of suction (n = 1) and perforation (n = 4). No conversion to penetrating keratoplasty was necessary. After surgery, double anterior chamber was observed in 2 cases (2.5%), both managed successfully by air filling of the anterior chamber. Stromal rejection was observed in 6 eyes (7.5%) and was reversed with topical steroids in all cases.
In keratoconic eyes without deep stromal scars, the combination of a graft larger than conventional ones with limited removal of deep stroma can improve visual and refractive outcomes of DALK, while minimizing the rate of complications.
评估 9mm 深板层角膜移植术（DALK）的结果，该手术中去除的深层基质仅限于中央 6mm 光学区。
前瞻性、非对照、干预性病例系列研究。
共 80 例连续的圆锥角膜眼，术后至少 1 次检查，且在完全去除缝线后 1 个月。
进行标准化的 DALK，包括（1）受体床深度为 450 至 550μm、直径为 9mm 的深环钻；（2）气动分离；（3）约 80%的前基质消薄；（4）从中央 6mm 光学区去除深层基质（气泡顶）；（5）移植由微角膜刀辅助分离（400-μm 头）切割的 9mm 前角膜层，并以双行 10-0 尼龙缝线缝合。
获得的气动分离类型和成功率；最佳矫正视力（BCVA）、屈光性散光（RA）和角膜散光（TA）、术后 12 个月的中央角膜厚度（CCT）和内皮细胞密度；术中及术后并发症。
67 只眼（83.7%）中的 80 只眼（67.5%）形成了“大气泡”，其中 1 只眼（1.5%）除外，根据 Dua 等人的分类，均为 1 型。完全去除缝线后，BCVA 平均为 0.09±0.72 最小分辨角对数（logMAR），28 只眼（35%）≥20/20，54 只眼（67.5%）≥20/25，76 只眼（95%）≥20/40；RA 平均为 3.10±1.30 屈光度（D），73 只眼（91%）在 4.5D 以内，无一例超过 6D；72 只眼（90%）检测到规则 TA；平均 CCT 为 492±62.10μm；术后内皮细胞密度平均为 2026±397cells/mm，平均细胞丢失率为 11.2%。术中并发症包括吸力丧失（n=1）和穿孔（n=4）。无病例需转为穿透性角膜移植。术后，2 例（2.5%）出现双前房，均通过前房充气成功处理。6 只眼（7.5%）出现基质排斥反应，所有病例均通过局部皮质类固醇逆转。
在无深层基质瘢痕的圆锥角膜眼中，与传统方法相比，移植更大的移植物并去除深层基质的范围有限，可改善 DALK 的视力和屈光结果，同时将并发症发生率降至最低。
