Krumeich J H, Daniel J
Martin-Luther-Hospital, Bochum.
Klin Monbl Augenheilkd. 1997 Aug;211(2):94-100. doi: 10.1055/s-2008-1035103.
Perforating keratoplasty (PKP) for the treatment of keratoconus is a temporary procedure that sacrifices the healthy recipient endothelium. As an alternative to PKP we perform live-epikeratophakia (L-EPI) in keratoconus I-II and deep lamellar keratoplasty (DLKP) in keratoconus II-III.
20 patients with keratoconus were operated on either with L-EPI for keratoconus I-II (n = 10) or DLKP for keratoconus II-III (n = 10) respectively. In all cases, corneal tissue eligible for corneal transplantation was used. L-EPI: The corneal lenticule was prepared by means of the Barraquer-Krumeich-Swinger (BKS) set. The recipient cornea was trephined to a depth of 0.3 mm with the Guided-Trephine-System (GTS). The incision was extended manually (inner diameter 7.0 mm, outer diameter 9.0 mm). No keratectomy was performed. The lenticule was fixed with a 10 x 0 nylon double-running anti-torque suture (DRA). DLKP: The recipient cornea was trephined with the 8.0 mm GTS to a depth of 0.68 mm. A lamellar removal of the upper layers was performed by hand. After mechanical removal of the graft endothelium, the remaining full thickness donor cornea was sutured into the bed with a 10 x 0 nylon DRA suture.
L-EPI: Within this series, there was no disturbance of the healing process. Spherical equivalent and corneal astigmatism remained stable from the first month on. Visual acuity of 20/40 or better was obtained in 40% of the cases at 1 month, 53% at 6 months, and 100% at 1 year and 2 years. We did not observe any late decline of VA. Two patients with kerato-conus borderline stage II did not reach useful VA due to insufficiently reduced pre-existing irregular corneal astigmatism. These patients successfully underwent DLKP at 8 and 10 months respectively. DLKP: Except for 1 case (neurodermatitis), all lenticules remained stable with respect to refraction and radii up to the longest follow-up of 2 years. Starting from the first month on, refraction was stable. Visual acuity of 20/40 or better was reached in 33% of the cases at 1 month, in 56% at 6 months, and in 89% at 1 and 2 years. We did not administer systemic cyclosporine-A in either group. In the lamellar techniques presented, we did not observe any graft rejection. According to corneal topography, corneal astigmatism, spherical equivalent, and keratometry we did not observe any late re-onset of a progression of the cone.
In patients with keratoconus stage I to III, L-EPI or DLKP appeared to be very useful therapies. Both procedures seem to end progression of the disease and allow to preserve the healthy recipient endothelium. If unsuccessful, either procedure may be repeated. Neither procedure precludes possibly later needed PKP.
穿透性角膜移植术（PKP）用于治疗圆锥角膜是一种临时性手术，会牺牲健康的受体内皮细胞。作为PKP的替代方法，我们对I-II期圆锥角膜患者施行活上皮角膜磨镶术（L-EPI），对II-III期圆锥角膜患者施行深板层角膜移植术（DLKP）。
20例圆锥角膜患者分别接受了L-EPI治疗I-II期圆锥角膜（n = 10）或DLKP治疗II-III期圆锥角膜（n = 10）。所有病例均使用了适合角膜移植的角膜组织。L-EPI：使用Barraquer-Krumeich-Swinger（BKS）设备制备角膜透镜。用引导式环钻系统（GTS）将受体角膜钻至0.3 mm深度。手动扩大切口（内径7.0 mm，外径9.0 mm）。未进行角膜切除术。用10×0尼龙双行抗扭缝线（DRA）固定角膜透镜。DLKP：用8.0 mm GTS将受体角膜钻至0.68 mm深度。手工进行上层板层切除。机械去除植片内皮后，用10×0尼龙DRA缝线将剩余的全层供体角膜缝合到植床上。
L-EPI：在该系列中，愈合过程未受干扰。从第一个月起，球镜当量和角膜散光保持稳定。1个月时40%的病例视力达到20/40或更好，6个月时为53%，1年和2年时为100%。我们未观察到视力的任何后期下降。两名处于圆锥角膜临界II期的患者因术前不规则角膜散光未充分降低而未获得有用视力。这两名患者分别在8个月和10个月成功接受了DLKP。DLKP：除1例（神经性皮炎）外，所有角膜透镜在长达2年的最长随访期内屈光和曲率半径均保持稳定。从第一个月起，屈光稳定。1个月时病例中33%的视力达到20/40或更好，6个月时为56%，1年和2年时为89%。两组均未给予全身性环孢素A。在所示的板层技术中，我们未观察到任何植片排斥反应。根据角膜地形图、角膜散光、球镜当量和角膜曲率计，我们未观察到圆锥进展的任何后期复发。
对于I至III期圆锥角膜患者，L-EPI或DLKP似乎是非常有用的治疗方法。两种手术似乎都能终止疾病进展并保留健康的受体内皮细胞。如果不成功，两种手术均可重复。两种手术均不排除后期可能需要的PKP。
