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Deep anterior lamellar Deep anterior lamellar keratoplasty in keratoplasty in children children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick Children Toronto, Ontario, Canada Disclosure: The author has no financial interests related to the material of this poster.
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Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Jan 14, 2016

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Page 1: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Deep anterior lamellar Deep anterior lamellar keratoplasty in childrenkeratoplasty in childrenWorld Cornea Congress April 2010Boston, MA

Asim Ali, MD, FRCSCUniversity of TorontoHospital for Sick ChildrenToronto, Ontario, Canada

Disclosure: The author has no financial interests related to the material of this poster.

Page 2: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

AbstractAbstractPurposeTo present a series of pediatric patients who underwent deep anterior lamellar keratoplasty (DALK) for stromal opacities or ectasia by one surgeon from 2007-2009. MethodsA retrospective review of 12 consecutive patients with attempted DALK, age less than 18 years and follow-up of at least 4 months was performed. Indications for surgery, length of follow-up, complications and initial and final visual acuity were recorded. Results Successful DALK was performed in 12 eyes of 11 patients aged 1-17 years old. There was one macroperforation and conversion to penetrating keratoplasty. Non-healing epithelial defects occurred in 2 patients who developed microbial keratitis. Repeat DALKs were performed successfully. One patient developed reactivation of HSV in the graft and because of dense amblyopia a repeat graft was not attempted. Final visual acuity was unchanged or improved in all patients. ConclusionsDeep anterior lamellar keratoplasty is a safe alternative to penetrating keratoplasty in children with corneal stromal opacities or ectasia.

Page 3: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

MethodsMethodsRecords of 13 eyes of 12

consecutive patients with attempted DALK were reviewed

Single surgeon from 2007-09Surgical technique used

◦Melles technique (1 case)◦Manual dissection (12 cases)

Trephination (Hessberg-Barron, 300-350 microns)

Sharp and semi-sharp dissection to pre-Descemet’s plane

Air injected to visualize stroma but big bubble not attempted

Page 4: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

ResultsResults12/13 eyes underwent successful manual

DALK1 eye was converted to PKP because of

macroperforation4 microperforations occurred but

dissection was completed successfully2 repeat DALKs (with tarsorraphy) were

performed after persistent epithelial defects resulted in bacterial keratitis – both remain clear

Vision remains unchanged or improved in all patients

Grafts are clear in 11/12 eyes with mean follow-up of 11.8 months (range 6-22)

Page 5: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Table 1: Pre-operative Table 1: Pre-operative characteristicscharacteristicsPatient

Age Eye

Diagnosis Other Pre-op BCVA

1 9 mo RE Herpes simplex CS UM*

2 9 yr RE Phlectenulosis 20/400

3 14 yr

RE Keratoconus Autism, eye-rubber Fix + follow

14 yr

LE Keratoconus Fix + follow

4 15 yr

RE Hurler syndrome 20/200

5 1 yr LE Corneal dermoid Linear nevus sebaceous

CS UM*

6 8 yr LE ? Herpes zoster 20/100

7 2 yr LE Bacterial keratitis Neurotrophic cornea LP

8 16 yr

LE Keratoconus Eye-rubber, OCD, Tourettes

CF

9 8 yr RE Descemetocele Posterior blepharitis 20/40

10 14 yr

LE Bacterial keratitis Soft contact lens wearer

20/70

11 5 yr RE Exposure keratopathy

Goldenhar syndrome, lid coloboma repair

20/800

12 13 yr

LE Keratoconus CF

* Central, steady + unmaintained

Page 6: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Table 2: Operative detailsTable 2: Operative detailsPatient

Eye

Residual opacity

Donor/recipient (mm)

Intraoperative complications / comments

1 RE - - Macroperforation, converted to PKP

2 RE No 7.75 /7.5 None

3 RE No 7.75 /7.5 None

LE No 8.0 /7.5 None

4 RE Yes 8.0 /7.5 Microperforation

5 LE No 7.0 /6.5 Previous crescentic graft, subsequent cataract extraction /IOL /pupilloplasty

6 LE Yes 8.0 /7.5 Microperforation

7 LE No 7.25 /7.0 None

8 LE No 8.5 /8.0 None

9 RE Yes 7.75 /7.5 Microperforation

10 LE No 8.25 /8.0 Microperforation

11 RE No 7.75 /7.5 None

12 LE No 8.0 /7.5 None

Page 7: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Table 3: Post-operative courseTable 3: Post-operative coursePatient

Eye

Complications Post-op BCVA

Follow-up

Comments

1 RE Graft rejection 20/200

2 RE None 20/40 22 mo Ambylopia

3 RE None 20/40 12 mo

LE None 20/50 6 mo

4 RE None 20/80 6 mo Sutures in

5 LE None 20/200 20 mo Dense amblyopia

6 LE Suture loosening at 6 weeks

20/60 11 mo Amblyopia

7 LE ? HSV reactivation + scar

HM 13 mo Opted not to regraft

8 LE None 20/40 8 mo

9 RE Persistent epi defect, bacterial ulcer, regraft

20/40 22 mo Tarsorraphy

10 LE None 20/20 12 mo

11 RE Persistent epi defect, bacterial ulcer, regraft

20/200 14 mo Amblyopia

12 LE None 20/50 6 mo

Page 8: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Figure 1: Slit lamp photo of patient 6showing anterior stromal scar and thinning

Page 9: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

Figure 2: Slit lamp photo of patient 12 showing Vogt striae and deep scarring

Page 10: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

DiscussionDiscussionDALK was selected instead of PKP in our pediatric patients

because of a lower risk of rejection and greater tectonic strength. Two of our patients (3 and 8) were forceful eye rubbers with psychiatric co-morbidities and the improved strength was reassuring.

A manual technique instead of a big bubble technique was used to allow dissection of deep scars and minimize perforations, as we believe the benefit of reduced rejection outweighs the visual benefits in this patient group with other ocular co-morbidities especially amblyopia.

The high rate of perforation may reflect the deep scarring in some corneas and also surgeon inexperience.

Satisfactory visual outcomes were achieved even when residual corneal opacities remained in the recipient bed.

Persistent epithelial defects lead to bacterial superinfection in two patients and we now perform temporary and permanent tarsorraphies following DALK surgery in susceptible patients.

Page 11: Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick.

ConclusionsConclusionsManual DALK in children leads to

improved visual outcomes, and in our view has significant advantages over PKP in this high risk group.