Indication, results, and long survival in DALK

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Indication, results, and long survival in DALK

Symposium 12: Anterior Lamellar Keratoplasty

Clinica degli occhi

Sarnicola

Vincenzo Sarnicola, MD Grosseto, Italy

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No financial interest to disclose.

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LONG TERM

GRAFT SURVIVAL

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PURPOSE

• 10 years DALK graft survival

PARTICIPANTS

• 806 DALK/ 711 patients

• Between 2000-2009

• Exclusion criteria:

– Follow-up < 6 months

– Lost from follow-up visit

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YEARS

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Number of procedures

(660 DALK)

32

38

51

59

66

76

88

79

80

91

Diagnosis

Keratoconus

(490= 74%)

22

(70%)

29

(75%)

36

(70%)

43

(73%)

53

(80%)

49

(65%)

70

(80%)

55

(70%)

60

(75%)

73

(80%)

Herpetic keratitis

(98=15%)

6

(18%)

6

(20%)

6

(12%)

9

(15%)

8

(12%)

12

(15%)

9

(10%)

16

(20%)

12

(15%)

14

(15%)

Other opacities

(72=11%)

4

(12%)

3

(5%)

9

(18%)

7

(12%)

5

(8%)

15

(20%)

9

(10%)

8

(10%)

8

(10%)

4

(5%)

INDICATIONS

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Endothelial Cell Loss / 269 eyes

Preoperatively

(cells/mm2)

At 6 months

(cells/mm2)

At 1 year

(cells/mm2)

Mean 2705.9 2420.0 2403.8

ECL =

10-11%

Vincenzo Sarnicola

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Rejection 26/660 (4%)

Subepithelial infiltrates (0.2 - 0.5 mm. size) confined to the donor tissue

Cellular infiltrates in the epithelium. Early in the postoperative time 1-13 m.

Epithelial rejection 2 cases Subepithelial rejection 24 cases

Postop Protocol: Dexamethasone drops 3 times/day/ first 3 week

s

Loteprednol drops 3 times/day/ 4th-9th week

Loteprednol drops 1 time/day/long period

Epithelial and subepithelial rejection rate: 4-11% in literature

Stromal rejection rate: 3% in literature

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Long term GRAFT SURVIVAL

660 eyes

502 patients

2000-2001

(70 cases)

2002-2003

(110 cases)

2004-2005

(142 cases)

2006-2007

(167 cases)

2008-2009

(171 cases)

Survival rate

(average 99,3%)

98,5%

(69)

99%

(109)

100% 99,5%

(166)

99,5%

(170)

Follow –up

(average 54,3 m)

9-10 yrs 8-7 yrs 6-5 yrs 4-3 yrs 2-1 yrs

G

R

A

F

T

F

A

I

L

U

R

E

0,6%

Number

/Causes

1 (1,42%)

Pseudomonas

graft infection

1 (0,9%)

Corneal ulcer in

OSD

1(0,5%)

Iatrogenic

intra and post

op endothelial

damage

1 (0,5 %)

Herpes

infection by

donor tissue

trasmission

(late

diagnosis)

DALK

indication

DALK for CK DALK after OS

recostruction in

alcali burn

Stromal

distrophy

DALK for CK

Time of graft

failure

8 months post op 7 months post

op

One year post

op

One month

post op

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• Graft survival 98.5% /10 years fw-up DALK

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• Graft survival 98.5% /10 years fw-up

• Graft survival average

- 99,3 %

- 54,6 months fw-up

DALK

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- 99,3 %

- 54,6 months fw-up

• Graft failure 0,60%

first 2 yrs post (Early failure)

DALK

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- 99,3 %

- 54,6 months fw-up



DALK

• Survival of graft after 2 yrs is not “time dependent”

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- 99,3 %

- 54,6 months fw-up



DALK


- Enough ECC Not fo

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- 99,3 %

- 54,6 months fw-up



DALK

PK


- Enough ECC

- Recovery of OS defense

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RESULTS

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DESCEMETIC

(dDALK)

PRE-DESCEMETIC

(pdDALK)

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Visual acuity dDALK / pdDALK

0

1

2

3

4

5

6

7

8

9

10

Preop UCVA 18,5 m BSCVA 30,4 m BSCVA

Follow up

Vis

ual

Acu

ity

pdDALK

dDALK

UCVA

Preop.

Postop.

UCVA

Postop.BSCVA At least 7/10

BSCVA

10/10

BSCVA

pdDALK 1,76/10 4.6/10 8.6/10 92/116(80%) 57/116(49%)

dDALK 1,85/10 4.9/10 8.8/10 186/219(85%) 107/219(49%)

48 months follow-up /120 eyes

Descemetic DALK and Predescemetic DALK: Outcomes in 236 Cases of Keratoconus. V.Sarnicola, P. Toro, D.Gentile, and S.Hannush. Cornea 2010;29:53-59

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pdDALK 593.58 µ ± 65.30

dDALK 575.14 µ ± 38.25

Central Corneal Thickness

Estimated residual

bed thickness <50μm

Descemetic DALK and Predescemetic DALK: Outcomes in 236 Cases of Keratoconus. V.Sarnicola, P. Toro, D.Gentile, and S.Hannush. Cornea 2010;29:53-59

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Paper Author Eyes DALK Residual bed thickness

BSCVA Follow-up

Am J Ophthalmol 2007;143:117-24

Fontana et al. 78 50 BB DALK - BB DALK > manual DALK

24months

28 manual DALK NO DATA


Ardjomand et al. (Larkin group)

17 6 DALK <20μ DALK ≅ PK 22 months

5 DALK 20-80μ DALK ≅ PK 22 months

6 DALK >80μ DALK < PK 22 months


Han et al. (Tan group)

25 14 aDALK - aDALK > mDALK

12 months 11 mDALK NO DATA

Ophthalmology 2011;118:209-218

Reinhart et al. AAO REVIEW

481 11 DALK/PK comparative studies

< 10 % DALK ≅ PK

Acta Ophthalmol Online 6Aug2012 DOI: 10.1111/j.1755-3 768.2012.4432.x

Fournie et al. 95 74 dDALK - dDALK > pdDALK dDALK ≅ pdDALK

2 years 5 years 21 pdDALK NO DATA


Romano et al. (Fontana group)

158 109 BB DALK BB DALK ≅ manual DALK

5 years

49 manual DALK

NO DATA

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• dDALK and pdDALK are the most adopted acronyms • dDALK comparable with PK • pdDALK comparable with dDALK

- Longer follow-up - Residual bed - <80 μm - Uniform thickness - Smooth surface 1971 1. DEEP INTERFACE

2. UNIFORM THICKNESS OF POSTERIOR LAYER

3. SMOOTH SURFACE OF THE GRAFTS

4. HIGH THICKNESS OF DONOR TISSUE

5. HIGH QUALITY OF DONOR TISSUE

6. UNIFORM TRACTION OF THE SUTURES

7. CLEAR INTERFACE

LITERATURE EVIDENCE

Barraquer JI. Lamellar Keratoplasty (Special Techniques). Annals of Ophthalmology. June 1971

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola

• Big bubble DALK (BB DALK)

• Maximum depth DALK (MD-DALK)

• Anwar DALK (aDALK)

• Descemet bared DALK

• Manual DALK (mDALK)

• Etc.

NOMENCLATURE

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola






• Etc.

• Predescemetic DALK (pdDALK)

• Descemetic DALK (dDALK)

NOMENCLATURE

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola






• Etc.



• Dua’s layer

NOMENCLATURE

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“...BB 1 cleaves off a distinct layer at the posterior surface of the corneal stroma

BB Type 1

• Well circumscribed • White egde • Up to 8.5mm diameter (max 9.0 mm and then pops) • Startes in the center and enlarge circumferentially • Popping pressure 1.4-1.5 bar • It is possible to peel off the DM witho

ut deflating the BB Not for R

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“….BB type 2 cleaves off DM and stroma”

BB Type 2

• Thin wall • Clear egde • 10 mm diameter • Startes at the periphery • Popping pressure 0.6 bar • Peeling off the DM result in deflation of the BB • New air injection, after the DM peeling, can create a BB type 1 Not fo

r Release

DUA’S LAYER

….BB 1 cleaves off a distinct layer at the posterior surface of the corneal stroma,

which is not “residual stroma”…… (Dua’s Layer)

- HISTOLOGY: • This layer is acellular • Measured 10.15±3.6 microns • Composed of 5 to 8 lamellae of predominantly type 1 • collagen arranged in trasverse, longitudinal and oblique directions

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“…..anathomic descriptions….demonstrate the presence of keratocytes within 5 μm of the posterior lamina. This observation runs counter to a supposed hallmark of this so-called new layer, that is acellularity.”

“Although the observations presented are novel and illuminate an important mechanical response to acutley introduced nonphysiologic strain, in our opinion, The data presented do not warrant the assignation of a new anatomic layer to the cornea.”

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3 indipendent examiners observed

the histology of intact cornea

“......clearly argue against the existence of a distinctive acellular posterior layer

” FINDINGS:

1. Keratocytes present at 1.5 μm from DM in the central cornea and 5-9 μm the periphery 2. Collagen lamellae number not constant 3. Uniform collagen fibers diameter and interfibril spacing throughout the corneal stroma 4. Thin unaligned collagen fibers at the DM-stroma interface, ramdomly arranged

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“In their histologic studies of the pre-Descemet stroma, they describe “thin lamellae of thight packed collagen bundles running in longitudinal, trasverse, and oblique directions.”, this is normal anatomy. Not fo

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“Even though…

the existence of a new corneal anatomic layer is not

fully acctepted in literature….”

“Everybody should agree that…

Harminder Dua described, at least, the characteristics of a new surgical plane!!”

Vincenzo Sarnicola Asia Cornea Society, Seoul December 2016

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UNDOUBTED ADVANTAGES OF DUA’S INVESTIGATION

1- Classification of BB Type 1, Type2 and Type 3

• Dangerousness of BB Type2 • Maximum diameter of BB Type 1 • Visual outcomes • Characetristics of DM ruptures

2- Understanding of corneal biomechanics

• DALK better resistence following trauma vs PK • Acute hydrops in keratoconus • Resistance of Descemetocele before perforation • Recurrence of Macular dystrophy after BB Type 1 • Ect.

VERY IMPORTANT PRACTICAL APPLICATION

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HISTOLOGICAL CLASSIFICATION

pdDALK Bed thickness <80μ

dDALK BB type 2

•Layer by layer •Hydrodissection

•Peeling off

• • • • • •

•

Layer by layer

Hydrodissection

Peeling off

•BB type 1

BB type 1

Viscobubble

AVB

•Viscobubble •AVB

• BB type 2

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SURGICAL CLASSIFICATION


dDALK BB type 2

• • •

• • • •

Layer by layer

Hydrodissection

Peeling off

BB type 1

Viscobubble

AVB

• TALK (TOTAL)

• STALK (SUB-TOTAL)

• DALK (DEEP)

UNPUBLISHED NEW NOMENCLATURE

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INDICATIONS

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YEARS

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Number of procedures

(660 DALK)

32

38

51

59

66

76

88

79

80

91

Diagnosis

Keratoconus

(490= 74%)

22

(70%)

29

(75%)

36

(70%)

43

(73%)

53

(80%)

49

(65%)

70

(80%)

55

(70%)

60

(75%)

73

(80%)

Herpetic keratitis

(98=15%)

6

(18%)

6

(20%)

6

(12%)

9

(15%)

8

(12%)

12

(15%)

9

(10%)

16

(20%)

12

(15%)

14

(15%)

Other opacities

(72=11%)

4

(12%)

3

(5%)

9

(18%)

7

(12%)

5

(8%)

15

(20%)

9

(10%)

8

(10%)

8

(10%)

4

(5%)

INDICATIONS

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1.- DALK in EXTREME ECTASIA

2.- DALK in INFECTIONS

3.- DALK in CORNEAL PENETRATING WOUNDS

4.- DALK in OCULAR SURFACE DISEASES

DALK OTHER INDICATIONS

• Keratoglobus

• Scar • Active infections

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KERATOGLOBUS

Vincenzo Sarnicol

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pdDALK in KERATOGLOBUS

Vincenzo Sarnicola, ASCRS, Boston 2014

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POST-OP AFTER 20 DAYS

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EXTREME KERATOGLOBUS

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• Keratoglobus


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Preop UCVA: 1/10 (20/200) BSCVA: NI Ph: 3/10 (20/63)

1 year postop UCVA: 5/10 (20/40) BSCVA: 8/10 (20/25) -1.50 cyl 180 Ph: 10/10 (20/20)

HSV SCAR

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DALK

SYSTEMIC ACYCLOVIR

LOCAL LOTEPREDNOL

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Vincenzo Sarnicola, ASCRS, Boston 2014

5 MONTHS THERAPY (ORAL ACYCLOVIR, LOTEPREDNOL EYE DROPS)

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Preop One year post-op

UCVA 20/100 BSCVA 20/25 (+2cyl x 90°)

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HHV6 in GVHD

Phakic VA: HM

Pseudophakic VA: 3/10 (20/63) Not fo

r Release

HHV6 in GVHD

1 YEAR POSTOP

ACICLOVIR 800 mg/day LOTEPREDNOL BID

TARSORRHAPHY DOXYCYCLINE

ARTIFICIAL TEARS

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• Keratoglobus


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EARLY DALK in infectious keratitis

poorly responsive to medical treatment

• Significant ulcer (>150) in optical zone : (Presumed scar penalizing VA)

• Dangerousness of infection (Fungal and Acanthamoeba keratitis)

• Absence of prompt medical therapy response (NO reduction, or at least stabilization, of size lesion and/ or symptoms, after 1 week of targeted therapy)

• Patient’s compliance

Clinica degli occhi

Sarnicola

Vincenzo Sarnicola

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1 week post-op

• Cannula Big-bubble DALK

• Ø 9 mm

• No perforation

EARLY DALK IN ACANTHAMOEBA KERATITIS

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EARLY DALK IN ACTIVE FUSARIUM INFECTION

3 months post-op Not for R

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1.- DALK in ECTASIA




INDICATIONS

• Keratoconus • Keratoglobus


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PENETRATING WOUND -Man, 16 years old

- Penetrating corneal trauma OD (February, 2012)

- Visual acuity OD:

•20/200 -1 sph

- pdDALK March, 2013

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pdDALK in penetrating wound

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PREOP POSTOP

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1.- DALK in ECTASIA




INDICATIONS

• Keratoconus • Keratoglobus


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Chemical burn

V. Sarnicola, 2012

After autolimbal t

ransplantation

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“ ….the corneal endothelium and Descemet’s

membrane must remain intact if a corneal graft

was to succeed……”

Leber 1911

Mannis M, Mannis A. Corneal transplantation: a history in profiles. The monographs. 1999

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Grosseto (Tuscany) Italy

22-24 June 2017

The I nternational Congressof the I tal ian

Society of Stem Cellsand Surface

XVISI CSSO Congress

www.sicsso.org/congress2017

Mobile: +39 331 7073818 - Email: [email protected]

SAVE TH E D ATE

Teatro degli Industri

Clinica degli occhi S

arnicola

Grosseto (Tuscany) Italy

22-24 June 2017

The I nternational Congressof the I tal ian

Society of Stem Cellsand Surface

XVISI CSSO Congress

www.sicsso.org/congress2017

Mobile: +39 331 7073818 - Email: [email protected]

SAVE TH E D ATE

Teatro degli Industri

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Paper Author Eyes DALK Residual bed thickness

BSCVA Follow-up


Fontana et al. 78 50 BB DALK - BB DALK > manual DALK

24months

28 manual DALK

NO DATA


Ardjomand et al. (Larkin group)

17 6 DALK <20μ DALK ≅ PK 22 months

5 DALK 20-80μ DALK ≅ PK 22 months

6 DALK >80μ DALK < PK 22 months


Han et al. (Tan group)

25 14 aDALK - aDALK > mDALK

12 months 11 mDALK NO DATA

Ophthalmology 2011;118:209-218

Reinhart et al. AAO REVIEW

481 11 DALK/PK comparative studies

< 10 % DALK ≅ PK

Acta Ophthalmol Online 6Aug2012 DOI: 10.1111/j.1755-3 768.2012.4432.x

Fournie et al. 95 74 dDALK - dDALK > pdDALK dDALK ≅ pdDALK

2 years 5 years 21 pdDALK NO DATA


Romano et al. (Fontana group)

158 109 BB DALK BB DALK ≅ manual DALK

5 years

49 manual DALK

NO DATA

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola






• Etc.

NOMENCLATURE

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola






• Etc.



VISUAL OUTCOME

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola






• Etc.



VISUAL OUTCOME

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JOSE’ BARRAQUER

1971

1. DEEP INTERFACE

2. UNIFORM THICKNESS OF POSTERIOR LAYER

3. SMOOTH SURFACE OF THE GRAFTS

4. HIGH THICKNESS OF DONOR TISSUE

5. HIGH QUALITY OF DONOR TISSUE

6. UNIFORM TRACTION OF THE SUTURES

7. CLEAR INTERFACE

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Clinica degli occh

i Sarnicola

Vincenzo Sarnicola






• Etc.



VISUAL OUTCOME

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ADAM EVE

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HISTOLOGICAL CLASSIFICATION


dDALK BB type 2

•Layer by layer •Hydrodissection

•Peeling off

• • • • • •

•

Layer by layer

Hydrodissection

Peeling off

•BB type 1

BB type 1

Viscobubble

AVB

•Viscobubble •AVB

• BB type 2

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SURGICAL CLASSIFICATION


dDALK BB type 2

• • •

• • • •

Layer by layer

Hydrodissection

Peeling off

BB type 1

Viscobubble

AVB

• TALK (TOTAL)

• STALK (SUB-TOTAL)

• DALK (DEEP)

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BB opening Clinica degli occhi

Sarnicola

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Sarnicola

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Sarnicola

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Sarnicola

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DALK for KERATOCONUS: STANDARD TECHNIQUE

TODAY

Clinica degli occhi

Sarnicola

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Standard Tecnique

3 Surgical Patterns

Cannula Big Bubble

Cannula Air-visco bubble

Layer by layer

dDALK

pdDALK

Clinica degli occhi

Sarnicola

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Standard Tecnique

3 Surgical Patterns

Cannula Big Bubble


Layer by layer

dDALK

pdDALK

Clinica degli occhi

Sarnicola

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Sarnicola DALK spatula and cannula (2007)

Clinica degli occhi

Sarnicola

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Many other cannulas!!!

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Cannula BB Clinica degli occhi

Sarnicola

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Cannula 27G

Clinica degli occhi

Sarnicola

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Sarnicola

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Sarnicola

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Bubble test Clinica degli occhi

Sarnicola

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BB Test Clinica degli occhi

Sarnicola

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New technique for BB opening

Clinica degli occhi

Sarnicola

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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Clinica degli occhi

Sarnicola


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Standard Tecnique

3 Surgical Patterns

Cannula Big Bubble


Layer by layer

dDALK

pdDALK

Clinica degli occhi

Sarnicola

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Cannula AVB Clinica degli occhi

Sarnicola

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Cannula AVB Clinica degli occhi

Sarnicola

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Standard Tecnique

3 Surgical Patterns

Cannula Big Bubble


Layer by layer

dDALK

pdDALK

Clinica degli occhi

Sarnicola

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pdDALK Clinica degli occhi

Sarnicola

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• Keratoglobus


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Indication, results, and long survival in DALK

Documents