Corneal transplantation: Evolution and Innovations Korine van Dijk, Lisanne Ham, Lamis Baydoun, Vasilis Liarakos, Hilde van Esch, Jack Parker, Henny Otten, Isabel Dapena, Gerrit Melles
Netherlands Institute for Innovative Ocular Surgery, Melles Cornea Clinic Rotterdam, Amnitrans Eye Bank Rotterdam, The Netherlands
Corneal transplantation
• Introduction • Penetrating keratoplasty • Lamellar keratoplasty techniques • Deep anterior lamellar keratoplasty (DALK)
• Bowman layer implantation • Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) • Descemet membrane (automated) keratoplasty (DM(A)EK)
• Conclusion
History of keratoplasty 1789 Replacing opaque cornea by man-made material (De Quengsy GP: Precis au cours d´operations sur la chirurgie des yeux, Paris:Didot)
1818 Introduction of the term ´keratoplasty` (Reisinger F: Die Keratoplastik: Ein Versuch zur Erweiterung der Augenheilkunst, Bayrische Ann Chir Augenheilk)
1888 1st successful heterograft: anterior lamellar keratoplasty (v. Hippel: Eine neue Methode der Hornhauttransplantation, Graefes Arch Ophthalmol)
History of keratoplasty
1905 1st successful homologous penetrating keratoplasty (Zirm E., Eine erfolgreiche totale Keratoplastik. Graefes Arch Ophthalmol,1906)
Penetrating keratoplasty Traditional PK All disorders
Mushroom PK Stromal disorders
Top hat PK Endothelial disorders Tan and Heng. Clin Ophthalmol. 2013
PK - Limitations
Maumenee. Am. J. Ophthalmology 1950; Pineros et al. Arch Ophthalmol 1996; Jonas et al. Am J Ophthalmol 2002; Elder et al. Cornea 2004
PK - Indications
25% Keratoconus 10% (Superficial) scars
40-50% Endothelial disease (FED, PPBK, PEX)
Cursiefen et al. Changing Indications for penetrating keratoplasty, Cornea 1998 Eyebank Association of America, Statistical report, 2005
Penetrating keratoplasty Lamellar keratoplasty Full thickness
Anterior
Posterior (EK)
PKP
(D)ALK
DS(A)EK
DMEK
Open sky procedure
yes
no
no
no
Wound / suture related problems
yes
yes
no
no
Visual recovery
slow
faster
fast
very fast
Rejection
average
low
low
low
8
Lamellar keratoplasty •
Donor tissue not suitable for PK or anterior LK may be suitable posterior LK.
•
Donor tissue not suitable for PK or posterior LK may be suitable anterior LK
•
“Double use” of 1 donor cornea
Lie et al. 2010; Heindl et al. 2011; Ólafsdóttir 2011, Sharma et al. 2011, Groeneveld et al. 2012
Lamellar keratoplasty • (Deep) anterior lamellar keratoplasty ((D)ALK) • Only anterior part of the cornea replaced • Descemet and endothelium preserved
• Endothelial keratoplasty (EK) • Only posterior part of the cornea replaced • Anterior cornea not compromised
Lamellar keratoplasty
PK
DALK
DMEK DSEK
Deep Anterior Lamellar keratoplasty (DALK)
Netherlands Institute for Innovative Ocular Surgery, Melles Cornea Clinic, Amnitrans Eye Bank Rotterdam, The Netherlands
DALK
DALK: Indications
DALK: advantages Deep anterior lamellar keratoplasty (DALK) • • • • •
Less traumatic surgery Preserved ocular integrity Faster recovery Earlier suture removal Reduced risk of allograft rejection Minor loss of ECD Increased graft survival rate
Ing et al. Ophthalmology, 1998 Van Dooren et al. Am J Ophthalmol, 2004 Chung et al. Ophthalmologica, 2010 Borderie et al. Ophthalmology, 2011 Reinhart et al, Ophthalmology, 2011
DALK
DALK Dissection
•Anwar technique (“Big bubble” dissection) •NIIOS technique (Manual dissection with optical reference plane) Melles et al. BJO, 1999 Melles et al. Cornea, 2000 Anwar.& Teichmann. JCRS, 2002 Fontana et al. AJO, 2007 Villarubia et al. J Emmetropia, 2010 Baradaran-Rafii et al. Ophthalmol, 2012
DALK: Anwar “Big bubble” technique
Anwar & Teichmann. JCRS, 2002 17
DALK: NIIOS technique
DALK: NIIOS technique
DALK: Results
6m post-DALK
DALK: Results
2 years post-DALK
DALK: Results •
Complications • Intra-operative DM perforation (±10%)1-3 • Persistent epithelial defect (≈PK)3,4 • Allograft rejection (
