Early Results of Femtosecond Laser-Assisted Mushroom-Shaped Wound-Configurized Keratoplasty

Jae Sohn Byung; Kyun Kim Hong

doi:10.3341/jkos.2009.50.1.34

Journal List > J Korean Ophthalmol Soc > v.50(1) > 1008488

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Byung and Hong: Early Results of Femtosecond Laser-Assisted Mushroom-Shaped Wound-Configurized Keratoplasty

Original Article

J Korean Ophthalmol Soc 2009;50(1):34-43.

Published online: 7 September 2009

DOI: https://doi.org/10.3341/jkos.2009.50.1.34

Early Results of Femtosecond Laser-Assisted Mushroom-Shaped Wound-Configurized Keratoplasty

Jae Sohn Byung, M.D, Kyun Kim Hong, M.D, PhD

Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, Korea

Address reprint requests to Hong Kyun Kim, MD Department of Ophthalmology, Kyungpook National University #50 Samduk-2ga, Jung-gu, Daegu, 700-721, Korea Tel: 82-53-420-5816, Fax: 82-53-426-6552, E-mail: okeye@hanmir.com

Received 23 December 2008 Accepted 2 June 2008

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 report the results of femtosecond laser-assisted‘mushroom-shaped wound-configurized keratoplasty’in 6 patients based on the results of experimental models in rabbits’and enucleated porcine eyes.

Methods

Mushroom-shaped donor corneal grafts were designed and transplanted in 3 rabbit eyes and 10 enucleated porcine eyes. The histologic findings were observed and wound burst pressure compared between penetrating keratoplasty (PKP) and mushroom-shaped keratoplasty. The‘mushroom-shaped wound-configurized keratoplasty’was subsequently performed in 6 eyes of 6 patients.

Results

In all eyes of the rabbits, histologic findings showed stable wound structure. In the porcine models, mushroom-shaped keratoplasty showed a better resistance to IOP than PKP after complete suture. Patients who underwent the surgery showed an improvement of over 2 lines in Snellen visual acuity after the operation. The mean follow-up period was approximately 11 months. Complete suture removal was performed within 6 months and accurate and stable wound structure was identified.

Conclusions

Wound-configurized keratoplasty with femtosecond laser and mechanical dissection’has shown several advantages in the lamellar structure of the wound. Stable wound structure, less astigmatism, rapid suture removal and visual rehabilitation was achieved.

Keywords: Femtosecond laser, Mushroom-shaped keratoplasty

References

1. McNeill JI, Kaufman HE. A double running suture technique for keratoplasty: earlier visual rehabilitation. Ophthalmic Surg. 1977; 8:58–61.

2. Davison JA, Bourne WM. Results of penetrating keratoplasty using a double running suture technique. Arch Ophthalmol. 1981; 99:1591–5.

3. McNeill JI, Wessels IF. Adjustment of single continuous suture to control astigmatism after penetrating keratoplasty. Refract Corneal Surg. 1989; 5:216–23.

4. Musch DC, Meyer RF, Sugar A, Soong HK. Corneal astigmatism after penetrating keratoplasty. Ophthalmology. 1989; 96:698–703.

5. Van Meter WS, Gussler JR, Soloman KD, Wood TO. Postkeratoplasty astigmatism control. Ophthalmology. 1991; 98:177–83.

6. Assil KK, Zarnegar SR, Schanzlin DJ. Visual outcome after penetrating keratoplasty with double continuous or combined interrupted and continuous suture wound closure. Am J Ophthalmol. 1992; 114:63–71.

7. De Molfetta V, Brambilla M, De Casa N. . Residual corneal astigmatism after perforating keratoplasty. Ophthal-mologica. 1980; 179:316–21.

8. Perlman EM. An analysis and interpretation of refractive errors after penetrating keratoplasty. Ophthalmology. 1981; 88:39–45.

9. Samples JR, Binder PS. Visual acuity, refractive error, and astigmatism following corneal transplantation for pseudophakic bullous keratopathy. Ophthalmology. 1985; 92:1554–60.

10. Oh JW, Hahn TW, Park CK, Kim JH. Comparison of Corneal Astigmatism after Keratoplasty with 3 Kinds of Suture Techniques. J Korean Ophthalmol Soc. 1998; 39:2569–74.

11. Kim KE, Joo CK. Changes in Astigmatism after Suture Removal in Penetrating Keratoplasty. J Korean Ophthalmol Soc. 2003; 44:284–8.

12. Musch DC, Meyer RF, Sugar A. The effect of removing running sutures on astigmatism after penetrating keratoplasty. Arch Ophthalmol. 1988; 106:488–92.

13. Binder PS. The effect of suture removal on postkeratoplasty astigmatism. Am J Ophthalmol. 1988; 105:637–45.

14. Lin DT, Wilson SE, Reidy JJ. . Topographic changes that occur with 10-0 nylon suture removal following keratoplasty. Refract Corneal Surg. 1990; 6:21–5.

15. Mader TH, Yuan R, Lynn MJ. . Changes in keratometric astigmatism after suture removal more than one year after penetrating keratoplasty. Ophthalmology. 1993; 100:119–27.

16. Davis EA, Azar DT, Jakobs FM, Stark WJ. Refractive and keratometric results after triple procedure: experience with early and late suture removal. Ophthalmology. 1998; 105:624–30.

17. Kim KS, Kim MS. The Effect of PRK and LASIK for the Correction of Postkeratoplasty Astigmatism. J Korean Ophthalmol Soc. 2004; 45:376–82.

18. Binder PS, Abel R Jr, Polack FM, Kaufman HE. Keratoplasty wound separations. Am J Ophthalmol. 1975; 80:109–15.

19. Farley MK, Pettit TH. Traumatic wound dehiscence after penetrating keratoplasty. Am J Ophthalmol. 1987; 104:44–9.

20. Rehany U, Rumelt S. Ocular trauma following penetrating keratoplasty. Arch Ophthalmol. 1998; 116:1282–6.

21. Tseng SH, Lin SC, Chen FK. Traumatic wound dehiscence after penetrating keratoplasty. Cornea. 1999; 18:553–8.

22. Melles GR, Lander F, van Dooren BT. . Preliminary clinical results of posterior lamellar keratoplasty through a sclerocorneal pocket incision. Ophthalmology. 2000; 107:1850–6.

23. Alio JL, Shah S, Barraquer C. . New techniques in lamellar keratoplasty. Curr Opin Ophthalmol. 2002; 13:224–9.

24. Busin M. A new lamellar wound configuration for penetrating keratoplasty surgery. Arch Ophthalmol. 2003; 121:260–5.

25. Busin M, Arffa RC. Microkeratome-assisted Mushroom keratoplasty with minimal endothelial replacement Am J Ophthalmol. 2005; 140:138–40.

26. Hoffart L, Proust H, Matonti F. . Short-term results of penetrating keratoplasty performed with the Femtec femtosecond laser. Am J Ophthalmol. 2008; 146:50–5.

27. Por YM, Cheng JY, Parthasarathy A. . Outcomes of femtosecond laser-assisted penetrating keratoplasty. Am J Ophthalmol. 2008; 145:772–4.

28. Cheng YY, Tahzib NG, van Rij G, van Cleynenbreugel H, Pels E, Hendrikse F, Nuijts R. Femtosecond laser-assisted inverted mushroom keratoplasty. Cornea. 2008; 27:679–85.

29. Steinert RF, Ignacio TS, Sarayba MA. “Top Hat”-shaped penetrating keratoplasty using the femtosecond laser. Am J Ophthalmol. 2007; 143:689–91.

30. Seitz B, Behrens A, Langenbucher A. . Experimental 193-nm excimer laser trephination with divergent angles in penetrating keratoplasty. Cornea. 1998; 17:410–6.

31. Farid M, Kim M, Steinert RF. Results of penetrating keratoplasty performed with a femtosecond laser zigzag incision initial report. Ophthalmology. 2007; 114:2208–12.

32. Slade SG. Applications for the femtosecond laser in corneal surgery. Curr Opin Ophthalmol. 2007; 18:338–41.

33. Bahar I, Kaiserman I, McAllum P, Rootman D. Femtosecond laser-assisted penetrating keratoplasty: stability evaluation of different wound configurations. Cornea. 2008; 27:209–11.

34. Price MO, Price FW Jr. Efficacy of topical cyclosporine 0.05% for prevention of cornea transplant rejection episodes. Ophthalmology. 2006; 113:1785–90.

35. Filatov V, Steinert RF, Talamo JH. Postkeratoplasty astigmatism with single running suture or interrupted sutures. Am J Ophthalmol. 1993; 115:715–21.

36. Claesson M, Armitage WJ. Astigmatism and the impact of relaxing incisions after penetrating keratoplasty. J Refract Surg. 2007; 23:284–9.

37. Imaizumi T. Movement of corneal endothelium after penetrating keratoplasty. Observation of sex chromatin as a cell marker. Nippon Ganka Gakkai Zasshi. 1990; 94:928–36.

38. Groh MJ, Seitz B, Kuchle M, Naumann GO. Clearing of the host cornea after penetrating keratoplasty for pseudophakic bullous keratopathy. Klin Monatsbl Augenheilkd. 1999; 215:275–80.

39. Langenbucher A, Seitz B, Nguyen NX, Naumann GO. Corneal endothelial cell loss after nonmechanical penetrating keratoplasty depends on diagnosis: a regression analysis. Graefes Arch Clin Exp Ophthalmol. 2002; 240:387–92.

40. Patel SV, Hodge DO, Bourne WM. Corneal endothelium and postoperative outcomes 15 years after penetrating keratoplasty. Am J Ophthalmol. 2005; 139:311–9.

41. Gil SY, Park CK, Hahn TW. Evaluation of Donor Corneal Endothelium after Keratoplasty. J Korean Ophthalmol Soc. 2006; 47:519–24.

42. Price FW Jr, Price MO. Femtosecond laser shaped penetrating deratoplasty: one-year results utilizing a top-hat configuration. Am J Ophthalmol. 2008; 145:210–4.

43. Shimmura S. Component surgery of the cornea. Cornea. 2004; 23:S31–5.

Figure 1.

In porcine eyes on artificial chamber, wound burst pressures were recorded by digital manometer after 4, 8, 16 sutures. (A: Conventional PKP, B: Mushroom-shaped keratoplasty)

Figure 2.

Donor cornea mounted in an artificial chamber under the femtosecond laser and applanation was done.

Figure 3.

Illustration of the femtosecond laser-shaped penetrating keratoplasty “Mushroom-shaped” graft configuration.

Figure 4.

Histologic examination of rabbit’s cornea show accurate and stable wound structure.

Figure 5.

Postoperative slit-lamp photograph of patient 2 after ‘mushroom-shaped’ keratoplasty. Note the clear central cornea with well attached peripheral flange.

Figure 6.

Changes of mean best corrected visual acuity (BCVA) after Femtosecond laser-assisted ‘mushroom- shaped’ wound-configurized keratoplasty.

Figure 7.

Ultrasound biomicroscopic finding (above) and anterior OCT (below) of patient’s cornea show well attached stable wound structure as in rabbits’ model

Table 1.

Summary of age, gender, treated eye, diagnosis, preoperative BCVA, data of donor corneal cut of patients

Patient No.	Sex /Age (yr)	Diagnosis	Treated eye	Preoperative BCVA^∗(LogMAR)	design of donor graft (Anterior/Posterior/depth)(mm)
1	M/36	Corneal opacity d/t corneal injury	Right	0.4	8.2 / 6 / 0.32
2	M/27	Keratoconus Hydrops	Left	2	8.6 / 6 / 0.3
3	M/40	Corneal opacity d/t corneal injury	Left	1.6	8.2 / 6 / 0.35
4	M/28	Keratoconus Hydrops	Left	2	8.6 / 6 / 0.32
5	M/18	Keratoconus	Right	1.1	8.2 / 6 0.3
6	M/27	Keratoconus	Left	1	8.2 / 7 / 0.35

^∗ BCVA=best corrected visual acuity.

Table 2.

Mean burst pressure for traditional PKP and mushroom keratoplasty in porcine corneas

No. stitches	Traditional PKP∗ (n=5)	Mushroom keratoplasty (n=5)	P-value
4	1.2±1.1	2.4±0.55	0.10
8	16.6±6.23	27.4±7.37	0.10
16	78.4±19.71	133±24.6	0.008

^∗ PKP=penetrating keratoplasty; Values are mean± SD burst pressure (mmHg).

Table 3.

Summary of preoperative and postoperative endothelial cell count, time of suture removal and follow-up period

Patient	Preoperative Donor corneal endothelial cell count (cells/mm²)	endothelial cell count at last visit (cells/mm²)	Complete removal (week)	Follow-up period (week)
1	2375	1400	20	68
2	2157	1916	24	47
3	2364	1431	28	45
4	2577	1645	25	40
5	2427	2188	27	28
6	2680	2136	21	47
Mean± SD	2430±182	1786±345	24.2±3.2	45.8±13

Table 4.

Summary of refractive results, spherical equivalent, postoperative BCVA, corneal thickness, intraocular pressure after keratoplasty

Patient	6 months Sim K’s astigmatism (Diopter)	Spherical equivalent at final visit (Diopter)	Postoperative BCVA^∗ at final visit (LogMAR)	Corneal thickness at final visit (µm)	Postoperative IOP (mmHg)
1	3.1	1.25	0.2	554	11~22
2	1.5	-4	0.1	610	12~20
3	4	1.75	0	543	10~15
4	3.8	-10	0.2	511	12~18
5	2.8	-5.75	0.2	509	11~19
6	2.9	-12	0.3	630	15~20
Mean± SD	3.0±0.9	-4.79±5.7	0.17±0.1	559±50	15.4±4.2

^∗ BCVA=best corrected visual acuity.

TOOLS

Similar articles