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Two-step strategy—conjunctival flap covering surgery combined with secondary deep anterior lamellar keratoplasty for the treatment of high-risk fungal keratitis

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International Journal of Ophthalmology(English edition) 2023年第7期16卷 1065-1070页

作者： Yu-Chen Wang Jia-Song Wang Bei Wang Xi Peng Hua-Tao Xie Ming-Chang Zhang Department of Ophthalmology Union HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan 430022Hubei ProvinceChina

AIM:To investigate whether the two-step strategy[conjunctival flap covering surgery(CFCS)combined with secondary deep anterior lamellar keratoplasty(DALK)]is effective for patients with high-risk fungal keratitis(FK).METHODS:In this noncomparative,retrospective case series,10 subjects(6 males,4 females)with a mean age of 56.5±7.1(range 47-72)y with high-risk FK undergone the two-step strategy were included.Reported outcome measures were healing of the corneal ulcer,recurrence of FK,reject reaction,improvement in best corrected visual acuity(BCVA)and relevant complications.RESULTS:The average diameter of corneal infiltrates was 7.50±0.39 mm,ranging from 6.94 to 8.13 mm.The mean depth of corneal infiltrates was 422.4±77.1μm,ranging from 350 to 535μm.The mean corneal thickness was 597.4±117.3μm,ranging from 458 to 851μm.Hypopyon and endothelial plaques were presented in all patients.The period between the two steps was 3.65±0.9(ranging from 3 to 5)mo.The graft diameter was 7.75±0.39 mm.At the last follow-up(average 9.25±3.39,ranging from 5.5 to 17mo),no fungal recurrence or graft rejection appeared,and all patients showed improvement of BCVA.One patient suffered from liver function impairment due to oral voriconazole for 4wk and recovered spontaneously after 1wk of drug withdrawal.CONCLUSION:The two-step strategy is safe and effective in the treatment of high-risk FK by transforming intentional therapeutic penetrating keratoplasty during acute infection to later optical DALK.It is a practical strategy,especially in areas lacking fresh donor corneas and eye bank services.

关键词： high-risk fungal keratitis conjunctival flap deep anterior lamellar keratoplasty two-step strategy

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Femtosecond laser-assisted deep anterior lamellar keratoplasty in phototherapeutic keratectomy versus the big-bubble technique in keratoconus

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International Journal of Ophthalmology(English edition) 2018年第5期11卷 807-812页

作者： Jarbas Pereira de Macedo Lauro Augusto de Oliveira Flavio Hirai Luciene Barbosa de Sousa Department of Ophthalmology and Visual Sciences Escola Paulista de MedicinaUniversidade Federal de S?o Paulo

AIM：To compare the functional and anatomic results of femtosecond laser（FSL）-assisted deep anterior lamellar keratoplasty（DALK） associated with phototherapeutic keratectomy（PTK） and FSL-assisted DALK performed using the big-bubble technique in keratoconus.METHODS：During the first phase of the study,an electron microscopy histopathology pilot study was conducted that included four unsuitable donor corneas divided into two groups：in FSL group,FSL lamellar cuts were performed on two corneas and in FSL＋PTK group,PTK was performed at the stromal beds of two corneas after FSL lamellar cuts were made.During the second phase of the study,a randomized clinical trial was conducted that included two treatment groups of patients with keratoconus：group 1（n=14 eyes） underwent FSL-assisted DALK associated with PTK and group 2（n=12 eyes） underwent FSL-assisted DALK associated with the bigbubble technique.The main outcome measures were the postoperative visual acuity（VA） and optical coherence tomography（OCT） measurements,confocal microscopic findings,and contrast sensitivity.RESULTS：In the pilot study,histopathology showed a more regular stromal bed in the FSL＋PTK group.In the clinical trial,group 1 had significantly worse best spectaclecorrected VA and contrast sensitivity（P〈0.05 for both comparisons）.The residual stromal bed measured by OCT was significantly（P〈0.05） thicker in group 1.Confocal microscopy detected opacities only at the donor-receptor interface in group 1.CONCLUSION：Patients with keratoconus treated with FSL-assisted DALK performed using the big-bubble technique fare better than treated with FSL-assisted DALK associated with PTK.

关键词： deep anterior lamellar keratoplasty phototherapeutic keratectomy big-bubble technique keratoconus

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Femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus and keratectasia

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International Journal of Ophthalmology(English edition) 2014年第4期7卷 638-643页

作者： Yan Lu Yu-Hua Shi Li-Ping Yang Yi-Rui Ge Xiang-Fei Chen Yan Wu Zhen-Ping Huang Department of Ophthalmology Jinling Hospital School of Medicine Nanjing University

·AIM: To describe the initial outcomes and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty(DALK) for keratoconus and post-LASIK keratectasia.·METHODS: In this non-comparative case series, 10 eyes of 9 patients underwent DALK procedures with a femtosecond laser(Carl Zeiss Meditec AG, Jena,Germany). Of the 9 patients, 7 had keratoconus and 2had post-LASIK keratectasia. A 500 kHz VisuMax femtosecond laser was used to perform corneal cuts on both donor and recipient corneas. The outcome measures were the uncorrected visual acuity(UCVA),best-corrected visual acuity(BCVA), corneal thickness,astigmatism, endothelial density count(EDC), and corneal power.·RESULTS: All eyes were successfully treated. Early postoperative evaluation showed a clear graft in all cases. Intraoperative complications included one case of a small Descemet’s membrane perforation.Postoperatively, there was one case of stromal rejection,one of loosened sutures, and one of wound dehiscence.A normal corneal pattern topography and transparency were restored, UCVA and BCVA improved significantly,and astigmatism improved slightly. There was no statistically significant decrease in EDC.· CONCLUSION: Our early results indicate that femtosecond laser-assisted deep anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology. This approach shows promise as a safe and effective surgical choice in the treatment of keratoconus and post-LASIK keratectasia.

关键词： femtosecond laser deep anterior lamellar keratoplasty keratoconus post-LASIK keratectasia

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Refractive outcome of keratoconus treated by big-bubble deep anterior lamellar keratoplasty in pediatric patients: two-year follow-up comparison between mechanical trephine and femtosecond laser assisted techniques

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Eye and Vision 2019年第1期6卷 1-5页

作者： Luca Buzzonetti Gianni Petrocelli Paola Valente Sergio Petroni Rosa Parrilla Giancarlo Iarossi Ophthalmology Department Bambino GesùIRCCS Children’s HospitalVia Torre di Palidoro snc-00050 PassoscuroRomeItaly

Background:To evaluate refractive outcome 24 months after deep anterior lamellar keratoplasty(DALK)in pediatric patients by comparing results achieved using mechanical trephine and femtosecond laser.Methods:Twenty eyes of 20 patients affected by keratoconus were evaluated.To perform big-bubble DALK,10 eyes(Group 1;mean age 11.2±2.2 years)were subjected to the Hessburg-Barron mechanical trephine and the remaining 10 eyes(Group 2;mean age 11.3±3.1 years)to a 150 kHz femtosecond laser that performed mushroom incisions.Preoperative thinnest point in the corneal thickness map and K readings were measured by the Sirius Scheimpflug camera.We also evaluated corrected distance visual acuity(CDVA)as logMAR value using spectacles,spherical equivalent and refractive astigmatism.Results:Mean preoperative thinnest point and pre-and post-operative K readings did not show significant difference(P>0.05)between the two groups.CDVA,spherical equivalent and refractive astigmatism were respectively,0.14±0.08 logMAR and 0.13±0.10 logMAR(P=0.8),−4.2±1.1 D and−2.8±1.2 D(P=0.03),4.4±2.0 D and 3.6±1.2 D(P=0.4)in Groups 1 and 2.All DALK procedures were uneventful.Conclusion:Our findings suggest that femtosecond laser compared to mechanical trephine could significantly reduce the spherical equivalent amount in pediatric big-bubble DALK.

关键词： Pediatric keratoplasty deep anterior lamellar keratoplasty Femtosecond laser

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Graft rejection after deep anterior lamellar keratoplasty in fellow eye in macular corneal dystrophy: a case report

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Life Research 2022年第1期5卷 25-28页

作者： He Dong Jian Yu Xun Wang Jun-Zhang Li Department of Ophthalmology The Third People’s Hospital of DalianNon-Directly Affiliated Hospital of Dalian Medical UniversityDalianChina Department of Neurosurgery The Third People’s Hospital of DalianNon-Directly Affiliated Hospital of Dalian Medical UniversityDalianChina.

Because of the low incidence of immunological rejection,deep anterior lamellar keratoplasty(DALK)is currently the preferred treatment for macular corneal dystrophy(MCD).However,there were few reports about whether the consistent results were obtained when performing DALK in both eyes for MCD,especially when the corneal grafts were taken from different donors.Also,there were few reports about whether the stromal graft rejection occurred typically in both eyes in MCD with DALK.This case may represent the first report of an unusual and misleading manifestation of stromal graft rejection after uneventful DALK with big bubble technique in the fellow eye in MCD.A 32-year-old healthy man with MCD underwent bilateral uneventful DALK with a big bubble technique in the left eye in January and the right eye in July,the corneal grafts were taken from different donors.There was an atypical allograft rejection that occurred in the right eye and none in the left eye;although a timely diagnosis of graft rejection revealed following aqueous determination,it could not be reversed and underwent PK finally.The purpose of this case report is to illustrate the identification of atypical allograft rejection after DALK in the fellow eye,the significance of aqueous detection in the diagnosis of graft rejection,the choosing of grafts,and the timing of bilateral corneal transplantation in patients with MCD.

关键词： macular corneal dystrophy deep anterior lamellar keratoplasty postoperative rejection viral keratitis

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Donor cornea quality used for penetrating keratoplasty vs deep anterior lamellar keratoplasty

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World Journal of Ophthalmology 2014年第4期4卷 160-165页

作者： Sepehr Feizi Ophthalmic Research Center Labbafinejad Medical Center Shahid Beheshti University of Medical SciencesTehran 16666 Iran

deep anterior lamellar keratoplasty(DALK) has recently been introduced as an alternative procedure to penetrating keratoplasty(PK) for corneal pathologies not affecting the corneal endothelium. DALK does not rely on donor endothelium and requires less rigid criteria for donor corneal tissue quality. Therefore, DALK makes it possible to use donor corneas deemed unsuitable for PK. Furthermore, lamellar keratoplasty allows acellular corneal tissue to be transplanted. As a result, long-term preservation techniques are being revisited to increase the availability of donor corneas and subsequently alleviate constraints of availability, cost, storage, and transportation in many countries. The recent alterations in corneal transplantation techniques and hence the type of donor cornea tissues used for each technique, may require corneal surgeons and eye banks to reevaluate their selection criteria. The purpose of this systematic review is to present an updated analysis on the type and quality of donor corneas used for PK and DALK, assess the influence of donor and eye bank factors on the quality of donor corneas, and determine whether any of these donor factors affect clinical outcomes, complications, and graft survivals.

关键词： Corneal transplantation Penetrating keratoplasty Full-thickness keratoplasty deep anterior lamellar keratoplasty deep lamellar keratoplasty Maximum depth anterior lamellar keratoplasty Donor corneal quality Graft quality

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Rare giant corneal keloid presenting 26 years after trauma:A case report

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World Journal of Clinical Cases 2022年第27期10卷 9776-9782页

作者： Shang Li Jiang Lei Ying-Hui Wang Xiao-Lin Xu Ke Yang Ying Jie Beijing Institute of Ophthalmology Beijing Tongren Eye CenterBeijing Tongren HospitalCapital Medical UniversityBeijing Ophthalmology and Visual Sciences Key LabBeijing 100005China Department of Ophthalmology The First People's Hospital of Lanzhou CityLanzhou 730050Henan ProvinceChina

BACKGROUND Corneal keloid is a rare clinical disease with an unknown etiology,which is easily misdiagnosed.Surgery is the most effective treatment but is rarely reported in the literature.Herein,we report the clinical features,histopathology,and surgical outcome of a giant corneal keloid with trophoblastic vessels and discuss the genesis of the mass.CASE SUMMARY A 36-year-old young man was admitted to the hospital because of a large mass on the surface of the left cornea.The patient had suffered an injury to his left eye at the age of 6-years-old;however,as the injury did not cause cornea perforation,he did not undergo treatment.Slit lamp exam showed a large,elevated,opaque lesion that covered the entire cornea and protruded from the surface of the eyeball.anterior segment optical coherence tomography(AS-OCT) revealed a lesion of irregular density involving the anterior stroma.We suspected a secondary corneal fibroproliferative mass based on the clinical history,and slit lamp and AS-OCT findings.The patient subsequently underwent a superficial keratectomy and keratoplasty,and the final diagnosis of corneal keloid was confirmed by intraoperative histopathological examination.CONCLUSION Non-penetrating corneal trauma damages corneal epithelium basement membrane,initiating stromal fibrosis and causing corneal keloids.AS-OCT and biopsy confirm diagnosis.

关键词： Corneal keloid Histopathology Immunohistochemical staining anterior segment ocular coherence tomography deep anterior lamellar keratoplasty Case report

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Bowman layer transplantation in the treatment of keratoconus

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Eye and Vision 2018年第1期5卷 217-222页

作者： Diana C.Dragnea Rénuka S.Birbal Lisanne Ham Isabel Dapena Silke Oellerich Korine van Dijk Gerrit R.J.Melles Netherlands Institute for Innovative Ocular Surgery(NIIOS) Laan op Zuid 883071AA RotterdamThe Netherlands Melles Cornea Clinic RotterdamThe Netherlands. Amnitrans EyeBank RotterdamThe Netherlands NIIOS-USA San DiegoUSA

Several treatment options corresponding to the grade of keratoconus have been established.These are ultra-violet corneal crosslinking and intracorneal ring segments for mild to moderate keratoconus,and penetrating keratoplasty or deep anterior lamellar keratoplasty for the more advanced cases of keratoconus.Bowman layer transplantation was developed as a procedure for patients with advanced,progressive keratoconus.The technique consists of transplanting an isolated donor Bowman layer into a mid-stromal pocket of a keratoconic cornea resulting in corneal flattening and stabilization against further ectasia.Thus,it aims at corneal stabilization in eyes with advanced keratoconus,and enabling continued contact lens wear for normal visual functionality.By being a sutureless procedure and using an acellular graft,it potentially avoids commonly known suture and graftrelated complications of penetrating or deep anterior lamellar keratoplasty.The treatment seems to be a promising option in the management of advanced keratoconus in order to postpone or prevent a more invasive corneal surgery,while minimizing the risk of complications and allowing less stringent surveillance and less intensive medical therapy.

关键词： Cornea Advanced keratoconus Bowman layer Penetrating keratoplasty deep anterior lamellar keratoplasty Crosslinking Intracorneal ring segments

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Contralateral eye study of refractive,topographic and aberrometric outcomes after femtosecond assisted Myo Ring implantation and DALK for management of keratoconus

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International Journal of Ophthalmology(English edition) 2018年第10期11卷 1621-1630页

作者： Mohamed Omar Yousif Azza Mohamed Ahmed Said Department of Ophthalmology Faculty of Medicine Ain Shams University

AIM：To evaluate the efficacy of femtosecond laser assisted MyoRing intrastromal corneal implant and deep anterior lamellar keratoplasty （DALK） for management of moderate to advanced keratoconus regarding the degree of changes in visual acuity, refraction, corneal asphericity and aberrations.METHODS：A prospective non comparative interventional case study was conducted in Ophthalmology Department,Ain Shams University Hospital in the period from January 2015 to February 2017. The study included 30 eyes of moderate to advanced keratoconus. MyoRing was implanted in one eye （Group Ⅰ） and DALK operation was performed in the contralateral eye of the same patient （Group Ⅱ）.Preoperative and 6mo post-operative uncorrected visual acuity（UCVA）, corrected distance visual acuity （CDVA）, spherical equivalent （SE）, corneal and refractive astigmatisms,keratometry and Q-value using topography images were acquired. Quality of vision was assessed in all eyes including total corneal, anterior corneal high order aberrations analysis at 5 mm pupil size and the Strehl ratio of point spread function （PSF） as an objective measure of glare.RESULTS：Mean postoperative UCVA, CDVA, SE, refractive astigmatism,keratometryreadingsandasphericity were statistically improved compared to preoperative parameters in both groups （P〈0.05）. Significant reduction of all corneal aberrations following both techniques（P〈0.05） was achieved except mean trefoil and mean PSF in Group Ⅰ （P〉0.05）. Postoperative corneal aberrations were significantly lower in Group Ⅱ compared to Group Ⅰ.A statistically significant negative correlation was found in Group Ⅰ between the mean change in CDVA （logMAR）and the mean preoperative and mean postoperative total corneal aberrations root mean square （RMS; r=-0.78,P=0.04）. Also a statistically significant negative correlation was found between mean preoperative coma RMS and mean post PSF （r=-0.86, P=0.01）. In Group Ⅱ, there was a statistically significant positive correlation between mean change in CDVA （logMAR） and mean change in K

关键词： aberrations deep anterior lamellar keratoplasty femtosecond laser keratoconus MyoRing

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Corneal surgery in keratoconus: which type, which technique, which outcomes?

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Eye and Vision 2016年第1期3卷 8-21页

作者： Francisco Arnalich-Montiel Jorge L.Aliodel Barrio Jorge L.Alio IRYCIS.Ophthalmology Department Ramon y Cajal University HospitalMadridSpain Cornea Unit Hospital Vissum MadridMadridSpain Cornea and External Diseases Service Moorfields Eye HospitalLondonUK Cornea Cataract and Refractive Surgery UnitVissum CorporacionAlicanteSpain Division of Ophthalmology Universidad Miguel HernandezAlicanteSpain

Keratoconus is a disease characterized by progressive thinning,bulging,and distortion of the cornea.Advanced cases usually present with loss of vision due to high irregular astigmatism.A majority of these cases require surgical intervention.This review provides an update on the current treatment modalities of corneal surgery available for the management of advanced corneal ectasias.

关键词： Keratoconus deep anterior lamellar keratoplasty Penetrating keratoplasty Corneal transplant Rejection

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