Comparison of Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus

Kuk-Hyoe Kim; Kyeon Ahn; Eui-Sang Chung; Tae-Young Chung

doi:10.3341/jkos.2008.49.2.222

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Kim, Ahn, Chung, and Chung: Comparison of Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus

Original Article

J Korean Ophthalmol Soc 2008;49(2):222-229.

Published online: 31 August 2008

DOI: https://doi.org/10.3341/jkos.2008.49.2.222

Comparison of Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus

Kuk-Hyoe Kim, M.D., Kyeon Ahn, M.D., Eui-Sang Chung, M.D., Tae-Young Chung, M.D.

Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Address reprint requests to Tae-Young Chung, M.D., Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine #50 Ilwon-dong, Gangnam-gu, Seoul 135-230, Korea Tel: 82-2-3410-3569, Fax: 82-2-3410-0074, E-mail: tychung@skku.edu

Received 16 May 2007 Accepted 21 November 2007

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To compare the therapeutic outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PKP) in patients with keratoconus.

Methods

We retrospectively reviewed the clinical records of 57 patients diagnosed with keratoconus who had undergone DALK (19 eyes of 19 patients) and PKP (38 eyes of 38 patients) in Samsung medical center between January 1995 and January 2006.

Results

The 19 and 38 patients with keratoconus who underwent DALK and PKP had mean ages of 25.3 (range: 17-46) and 26.2 (range: 12-51) years, respectively. These groups were followed up for mean times of 16.7 (range: 6-34) and 45.7 (range: 6-115) months after surgery, respectively. The DALK group showed significantly higher values of refractive power, central corneal thickness, and endothelial cell density, while two eyes (10.5%) in the DALK group developed stromal rejection, which resolved after steroid therapy. In the PKP group, eight eyes (21%) developed endothelial rejection, among whom one eye (2.6%) resulted in a graft failure of a patient who underwent re-PKP, and two eyes (5.3%) in the PKP group developed secondary glaucoma.

Conclusions

DALK should be considered as the primary surgical technique in keratoconus, because the visual outcome is comparable with PKP and it reduces severe complications such as secondary glaucoma and the risk of graft failure by preserving the corneal endothelium compared to PKP.

Keywords: Deep anterior lamellar keratoplasty, Endothelial cell density, Keratoplasty, Keratoconus, Penetrating

References

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Figure 1.

Change of logMAR best-corrected visual acuity (BCVA) after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PKP). Mean BCVA preoperatively and up to the last follow-up after DALK (pink) and PKP (black) was provided. There were no statistical differences in BCVA between DALK and PKP groups throughout the observational period (Mann Whitney test).

Figure 2.

Difference of postoperative endothelial cell density between DALK (1958.6±455.1) and PKP (1390.4±460.2) group (p=0.01, Mann Whitney test). Specular microscopy was performed at median times of 26.0 months (DALK group) and 30.5 months (PKP group) postoperatively.

Figure 3.

Difference of postoperative central corneal thickness between DALK (553.9±44,4) and PKP (506.7±77.4) group (p=0.04, Mann Whitney test). Pachymetry was performed at median times of 26.0 months (DALK group) and 30.5 months (PKP group) postoperatively.

Table 1.

Demographic data of the patients who underwent deep anterior lamellar keratoplasty and penetrating keratoplasty

	DALK	PKP
Number of patients	19	38
Male: Female	17: 2	25: 13
Right: Left	12: 7	15: 23
Age at operation (Range)	25.26 years (17∼46)	26.23 years (12∼51)
Follow-up (Range)	17.4 months (12∼34)	47.4 months (12∼115)

Table 2.

Median values and mean differences of donor and recipient corneal diameter in both groups

	PKP (n=38)	DALK (n=19)
Donor diameter (median [interquartile range] mm)	8.0 [7.5∼8.5]	8.0 [7.75∼8.25]
Host diameter (median [interquartile range] mm)	7.75 [7.0∼ 8.0]	7.75 [7.5∼8.0]
Mean [donor diameter-host diameter]	0.31 [8.02-7.71]	0.32 [8.08-7.76]

Table 3.

Number of patients (n) whose final best-corrected visual acuity equals or is above 20/40 (LogMAR 0.3) in DALK and PKP groups (p=0.86, chi-square test)

	DALK (%)	PKP (%)
BCVA≥20/40	16	33
(LogMAR 0.3) (n)	(84.2%)	(86.48%)

Table 4.

Change of refractive data (value of spherical equivalent, sphere, cylinder) after DALK and PKP (at 6, 12 months and final follow-up after surgery). Degree of myopia in DALK group was statistically significant (p=0.04) at 6 months after surgery, but was not in 12 months and final follow-up, postoperatively (Mann Whitney test)

Mean±SD	Postoperative 6 months			Postoperative 12 months			Last follow-up
Mean±SD	SE^*	D sph	D cyl	SE^*	D sph	D cyl	SE^*	D sph	D cyl
DALK	−6.28±3.62	−4.29±3.88	−2.72±2.08	−5.71±5.05	−4.22±4.56	−4.55±3.34	−5.56±3.72	−4.04±4.13	−3.57±2.57
PKP	−3.91±3.37	−1.64±3.83	−4.54±3.02	−4.90±4.05	−2.73±3.81	−4.36±3.06	−4.41±3.59	−2.37±3.74	−4.02±2.87
P-value	0.04	0.01	0.04	0.14	0.06	0.34	0.26	0.13	0.73

^* SE=diopter spherical equivalent; D sph=diopter sphere; D cyl=diopter cylinder; SD=standard deviation.

Table 5.

Change of topographic data (Sim K's astigmatism, 3.0/5.0 mm zone mean power) 12 months after penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK). Corneal center was steeper in the DALK group significantly after surgery than PKP group (Mann Whitney test)

TOPO	DALK (D)	PKP (D)	p value
preop Sim K's astig.	193.32±166.49	208.32±515.53	p=0.109
preop 3.0 mean pwr	53.94±6.74	58.1±8.34	p=0.140
preop 5.0 mean pwr	48.77±0.22	51.69±6.07	p=0.208
postop Sim K's astig.	5.41±4.99	4.17±2.36	p=0.278
postop 3.0 mean pwr	46.94±4.37	45.01±3.80	p=0.040
postop 5.0 mean pwr	47.84±5.37	45.03±4.65	p=0.017

^* D=diopters; astig.=astigmatism; pwr=power.

Table 6.

The median values of post-operative time, at which specular microscopy and pachymetry was performed

	DALK (n=17)	PKP (n=28)
Median follow-up	26.0 (6-34) months	30.4 (6-96) months

Table 7.

Complication in the penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK)

PKP		DALK
Graft rejection	8 (21%)	Graft rejection	2 (10.5%)
Rejection episode	12	Rejection episode	2
Graft failure	1 (2.6%)	Graft failure	0 (0%)
2ndary glaucoma	2 (5.3%)	Conversion to PKP	4 (17.4%)

There were less severe complications such as graft failure and secondary glaucoma in the DALK group (p=0.01, chi-square test), though the rate of intra-operative conversion to PKP was not low.

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