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  5. FP93 : Intra-Operative DM Perforation During DALK-Our Results

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Dr. Shreesha Kumar K, K10064, Dr. Nitin Tiwari, Dr. Vamsi K

PURPOSE:

To analyzethe outcome of Intra-OperativeDescemet Membrane (DM) perforation during Deep Anterior Lamellar Keratoplasty (DALK)

METHODS:

Retrospective study of 169 eyes that underwent DALK between 2006-2015.Indications for surgery were advanced keratoconus in 99 eyes, macular grade corneal opacity in 40 eyes, macular dystrophy in 12 eyes,granular dystrophy in 11 eyes, spheroidal degeneration in 4 eyes and irregular cornea (post refractive surgery) in 3 eyes..

Surgery was perfomed under peribulbar anaesthesia. A partial thickness 360 degree trephination was done using a hand held disposable trephine and a small area along the trephine mark superiorly. This was then dissected using a crescent blade to introduce a needle for air injection. A 30 gauge needle attached to a 2cc syringe bent at 100 degree with bevel down was introduced to mid peripheral stroma and air bubble was injected with gentle force to obtain a big bubble or multiple bubbles. Superficial keratectomy was done and the big bubble was collapsed using an 11 no. blade. Viscoelastic substance was injected into the  incision to separate the posterior lamella and descemets and the posterior corneal lamella was divided into 4 quadrants and excised without disturbing the Descemets. The surface was then washed with saline to remove all visco-elastic substance. A donor tissue of the same size was stained with Trypan blue and the endothelium was removed using a non-toothed forceps. This donor button was then placed on the host bed and sutured to the host cornea using 10’0 monofilament nylon. 16 sutures were placed for larger sized graft (more than 8mm) and 12 sutures for smaller grafts. In cases where the big bubble could not be accomplished manual stromal dissection down to DM was performed using a crescent knife.

Intraoperative perforation of DM was noticed in different stages of the procedure right from injecting the airbubble into stroma to suturing of donor corneal button to host cornea

16 cases had intra operative DM perforation and 7 eyes needed conversion to PK and were excluded from the study. Those without DM Perforation (Group-1) and those with DM perforation (Group-2) were compared and analyzed. Main outcome measures were UCVA, BCVA, astigmatism, endothelial cell count and complications

RESULTS :The study was conducted in a tertiary eye care hospital and 169eyes were included for various indications during the period between July 2006 to June 2015. The age of our patients ranged from 16 to 58 years.Out of 16 cases with DM perforation 7 eyes needed conversion to PK.Perforation was seen in 15 eyes with manual dissection and 1 eye with big bubble technique. Mean BCVA in group-1 was 6/24 & 6/9 pre & post operatively andin group 2, 6/24 and 6/12.The mean astigmatism was 5.4D & 3.3Dpre & post-operatively in group1 and 5.2 & 3.1 D in Group 2.No significant difference in endothelial cell count was seen pre & post-operatively in Group 1 (2322+/-37cell/mm2 and 2274+/-29 c/mm2) but was statistically significant in group2(2341 +/-34c/mm2and 2131+/-35c/mm2)

Double anterior chamber was seen in 4 eyes, which needed air injection. 2 eyes had DM detachment which again needed descemetopexy post operatively. Raised intraocular pressure was noted in 3 eyes in Group 2, of which one was managed with antiglaucoma medications and the remaining 2 cases needed release of air bubble from anterior chamber..

CONCLUSION:. Deep anterior lamellar keratoplasty (DALK) is the surgery ofchoice for conditions requiring keratoplasty and restricted to the anterior layers of cornea without involving descemets and endothelial complex.

Perforation in DALK is not rare but with proper intra operative management, good results can be obtained.

References

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  2. Al-Torbak AA, Al-Motowa S, Al-Assiri A, Al-Kharashi S, Al- Shahwan  S, Al-Mezain H ,Teichmann K. Deep anterior  lamellar keratoplasty for  done  Cornea. 2007 Sep;26(8):1025-6.
  3. Vajpayee RB, Tyagi J, Sharma N, Kumar N, Jhanji V, Titiyal JS: Deep anterior lamellar keratoplasty by big-bubble technique for treatment corneal stromal opacities. Am J Ophthalmol. 2007 Jun;143(6):954-957.
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