Deep Anterior Lamellar Keratoplasty versus Penetrating

Keratoplasty for Macular Corneal Dystrophy:

A Randomized Trial
ES
_
IN SOGUTLU SAR
_
I, AN
_
IL KUBALOGLU, MUSTAFA UNAL, DAV
_
ID P
_
INERO, NURULLAH BULUT,
MUHAMMET KAZ
_
IM EROL, AND YUSUF O

ZERTU

RK
PURPOSE: To compare outcomes of big-bubble deep
anterior lamellar keratoplasty (DALK) and penetrating
keratoplasty (PK) for macular corneal dystrophy.
DESIGN: Prospective, randomized, interventional case
series.
METHODS: SETTING: Single hospital. PATIENTS: Eighty-
two eyes of 54 patients requiring keratoplasty for the
treatment of macular corneal dystrophy without endothe-
lial involvement were included. MAIN OUTCOME MEASURES:
Operative complications, uncorrected visual acuity, best-
corrected visual acuity, contrast sensitivity function,
higher-order aberrations, and endothelial cell density
were evaluated.
RESULTS: The DALK and PK group consisted of 35
and 41 eyes, respectively. Best-corrected visual acuity
after surgery was 20/40 or better 68.5% and 70.7% of
the eyes in the DALK and PK groups, respectively
(P>.05). No statistically signicant differences between
groups were found in contrast sensitivity function with
and without glare for any spatial frequency (P >.05).
Signicantly higher levels of higher-order aberrations
were found inthe DALKgroup (P<.01). Inbothgroups,
a progressive and statistically signicant reduction in
endothelial cell density was found (P < .01). At the
last follow-up, the mean endothelial cell loss was
18.1% and 26.9% in DALK and PK groups, respectively
(P [ .03). Graft rejection episodes were seen in 5 eyes
(12.1%) in the PK group, and regrafting was necessary
in 3 eyes (7.3%). Recurrence of the disease was docu-
mented in 5.7% and 4.8% of the eyes in the DALK and
PK groups, respectively.
CONCLUSIONS: Deep anterior lamellar keratoplasty
with the big-bubble technique provided comparable visual
and optical results as PK and resulted in less endothelial
damage, as well as eliminating endothelial rejection in
macular corneal dystrophy. Deep anterior lamellar kera-
toplasty surgery is a viable option for macular corneal
dystrophy without endothelial involvement. (Am J
Ophthalmol 2013;156:267274. 2013 by Elsevier
Inc. All rights reserved.)
M
ACULAR CORNEAL DYSTROPHY IS A BILATERAL
autosomal recessive disorder that may result in
signicant visual discomfort. It is characterized
by multiple grayish-white stromal opacities with indistinct
and hazy borders that extend from limbus to limbus. As
corneal opacity slowly becomes more dense and involves
the visual axis, loss of functional visual acuity occurs.
Therefore, keratoplasty eventually becomes necessary for
the restoration of vision and the recovery of corneal trans-
parency.
1
Traditionally, penetrating keratoplasty (PK) has been
considered as the denitive treatment option for a variety
of corneal pathologic features, including corneal stromal
dystrophies.
1,2
However, deep anterior lamellar
keratoplasty (DALK) currently is considered to be the
rst-choice surgical procedure in patients with corneal
disease not involving the endothelium, such as keratoco-
nus, stromal scars, and stromal dystrophies.
35
The
main advantage of DALK is that the patients own
endothelium is retained, which eliminates the risk of
endothelial graft rejection and preserves endothelial cell
density.
69
Although DALK has several advantages over
PK, there have been concerns about its role in macular
dystrophy because of the involvement of deeper layers of
stroma and possibly the Descemet membrane. Some
investigators believe that DALK is not suitable for the
treatment of macular corneal dystrophy, claiming that
the stromal and endothelial involvement as well as the
fragility of Descemet membrane in macular corneal
dystrophy would lead to interface opacities and higher
rates of endothelial cell attrition after DALK.
4,10
In the peer-reviewed literature to date, there are a few
reports comparing therapeutic outcomes of PK and
DALK surgery in the context of macular corneal
dystrophy.
4,10
In the current study, we prospectively
compared big-bubble DALK and PK in terms of optical
Accepted for publication Mar 7, 2013.
From Department of Ophthalmology, Medical Faculty, Balkesir
University, Balkesir, Turkey (E.S.S.); the Department of
Ophthalmology, Kartal Training and Research Hospital, Istanbul,
Turkey (A.K., N.B., Y.O

.); the Department of Ophthalmology, Akdeniz

University Medical Faculty, Antalya, Turkey (M.U.); the Departamento
de Optica, Farmacologa y Anatoma, Universidad de Alicante,
Alicante, Spain (D.P.); the Fundacionpara la Calidad Visual
(FUNCAVIS; Foundation for Visual Quality), Alicante, Spain (D.P.);
and the Department of Ophthalmology, Antalya Training and Research
Hospital, Antalya, Turkey (M.K.E.).
Inquiries to Esin Sogutlu Sar, Pasaalan mah, 253. sok, Deniz 2 apt,
No. 18 Daire. 4, Balkesir, Turkey; e-mail: [email protected]
0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2013.03.007
267 2013 BY ELSEVIER INC. ALL RIGHTS RESERVED.
and visual outcomes, complications, and their effect on the
endothelial cell density for the management of macular
corneal dystrophy.
METHODS
ALL PATIENTS WERE INFORMED ABOUT THE STUDY AS WELL
as the advantages and disadvantages of the procedure.
Informed consent was obtained from all patients to partic-
ipate in this research study in accordance with the Decla-
ration of Helsinki. The Institutional Review Board of
Kartal Training and Research Hospital, Istanbul, Turkey,
approved the study before it commenced. This study is
registered at http://www.controlled-trials.com with identi-
cation number ISRCTN41152132. This study was
a prospective, randomized clinical trial. Patients requiring
keratoplasty for the treatment of macular corneal dystrophy
without endothelial involvement were enrolled between
January 1, 2006, and June 1, 2010. Macular corneal
dystrophy diagnosis was made based on patient history,
family history, and slit-lamp ndings, including multiple
gray-white stromal opacities extending to the deep stroma.
Eighty-two eyes of 54 patients were included. All eyes were
assigned a number randomly based on a surgical chart (even
number, DALK; odd number, PK). Patients who were lost
to follow-up, who had undergone previous eye surgery, or
who underwent additional surgery combined with kerato-
plasty were excluded from the data analysis.
All eyes were operated on by a single experienced
surgeon (A.K.). Deep anterior lamellar keratoplasty was
performed by using the big-bubble technique previously
described by Anwar and Teichman.
11
When a big bubble
could not be obtained after repeated attempts, a layer-by-
layer manual dissection was performed. If during manual
dissection the bare Descemet membrane could not be
reached and diseased unclear stromal tissue remained, we
converted to PK.
Full-thickness corneoscleral donor buttons stored in
Optisol GS (Bausch and Lomb, Rochester, New York,
USA) were used for transplantation. Penetrating kerato-
plasty procedures were performed using the standard tech-
nique. The donor buttons in both the DALKand PKgroups
were sutured with a single continuous suture or interrupted
10-0 nylon sutures.
A complete ophthalmologic examination was performed
before the operation and postoperative visit in both groups.
The examination included logarithm of the minimal angle
of resolution uncorrected visual acuity (UCVA), logarithm
of the minimal angle of resolution best-corrected visual
acuity (BCVA), manifest refraction, slit-lamp bio-
microscopy, and corneal topographic analysis with the
CSO topography system (Costruzione Strumenti Oftal-
mici, Firenze, Italy). Contrast sensitivity measurements
and corneal aberrometric analysis also were performed after
surgery after all sutures were nally removed. The CSV-
1OOOE chart (VectorVision, Greenville, Ohio, USA)
was used for the assessment of contrast sensitivity. This
test consists of 4 rows of sine-wave gratings (3, 6, 12, 18
cycles/degree) that had to be observed by the patient
with full correction in place at a distance of 2.5 m. After
an initial demonstration, the contrast threshold was
measured for each spatial frequency. All patients were
tested under both mesopic and photopic conditions, and
the results were expressed in log units of contrast sensi-
tivity. Corneal aberrometry was recorded and analyzed
with the CSO topography system, whose software automat-
ically converts the corneal elevation prole into corneal
wavefront data using Zernike polynomials with an expan-
sion up to the seventh order. The corneal aberration
coefcients and root mean square (RMS) values were
calculated for a 6.0-mm pupil.
Endothelial cell density of donor corneas were assessed
by a specular microscope before storage in Optisol medium.
The endothelium was photographed and evaluated using
a Topcon SP 2000p noncontact specular microscope
(Topcon Corp, Tokyo, Japan). Images of the central
corneal window were reviewed by the same observer
(E S.), and manual correction of the cell borders was
performed before nal analysis of the endothelium. Twenty
endothelial cells were marked for each analysis. For each
examination, 3 measurements of endothelial cell density
were averaged.
Data were described as mean 6 standard deviation
(range). SPSS statistics software package version 15.0 for
Windows (SPSS, Chicago, Illinois, USA) was used for
statistical analysis. Normality of all data samples was
checked by means of Kolmogorov-Smirrnov test. When
parametric analysis was possible, the Student t test for
unpaired data was used for comparisons between PK and
DALK groups. When parametric analysis was not possible,
the MannWhitney U test was applied for between-group
comparisons. A P value less than .05 was considered statis-
tically signicant.
RESULTS
A TOTAL OF 82 EYES OF 54 PATIENTS WITH MACULAR
corneal dystrophy were included. An equal number of
eyes (41 eyes) underwent DALK and PK surgery. No intra-
operative complication occurred in the PK group. Conver-
sion to PK was needed in 6 eyes (14.6%) in the DALK
group because of macroperforation. Therefore, the data
analysis included 41 eyes in the PK group and 35 eyes in
the DALK group. Complete Descemet membrane exposure
was achieved in 27 eyes (77.1%; desmetic DALK
[dDALK]) via the big-bubble technique; however,
layer-by-layer manual stromal dissection was needed in
8 eyes (22.8%; predesmetic DALK [pdDALK]). Table 1
268 AUGUST 2013 AMERICAN JOURNAL OF OPHTHALMOLOGY
summarizes the preoperative conditions in the 2 groups of
eyes analyzed. As shown, no statistically signicant differ-
ences were found between the 2 groups in terms of age,
sex, or preoperative visual acuity.
The mean period between surgery and complete suture
removal was 14.0 6 3.4 months and 16.4 6 3.8 months
in DALK and PK groups, respectively (P .07). Mean
complete follow-up time was 30.5 6 8.75 months and
31.2 6 9.78 months in the DALK and PK groups, respec-
tively (P .53).
VISUAL OUTCOMES: After surgery, UCVA and BCVA
improved signicantly in both groups (P < .01). Table 2
summarizes the comparative outcomes at the last visit.
Logarithm of the minimal angle of resolution UCVA was
signicantly better in the PK group (P .02).
At the last follow-up, UCVA was 20/40 or better in 11
eyes (31.4%) in the DALK group and in 14 eyes (34.1%)
in the PK group (P > .05). Best-corrected visual acuity
was 20/40 or better in 24 eyes (68.5%) in the DALK group
and in 29 eyes (70.7%) in the PK group (P > .05). Uncor-
rected visual acuity was signicantly better in the dDALK
group than in the pdDALK group (P .04). Although not
signicant, BCVA also was better in dDALK group
(Table 3).
CONTRASTSENSITIVITYOUTCOMES: Figure 1 shows the
mean contrast sensitivity function under mesopic condi-
tions measured with and without a glare source. As shown,
no statistically signicant differences between groups were
found in contrast sensitivity measured without glare for any
spatial frequency (3 cycles/degree, P .39; 6 cycles/degree,
P .77; 12 cycles/degree, P .72; and 18 cycles/degree,
P .94). The same trend was observed for contrast sensi-
tivity measured with glare (3 cycles/degree, P .48; 6
cycles/degree, P .60; 12 cycles/degree, P .88; and 18
cycles/degree, P .80). Comparing the subgroups, the
mean contrast sensitivity function under photopic and
mesopic conditions were not different between the dDALK
and pdDALK groups for each of the spatial frequencies
(P > .05).
CORNEAL ABERROMETRIC OUTCOMES: Aberrometric
analyses were obtained in 27 eyes (77.1%) in the DALK
group and in 30 eyes (73.2%) in the PK group (Figure 2).
Signicantly higher levels of higher-order aberrations
(HOAs), primary coma aberrations, spherical aberrations,
and residual aberrations were found in the DALK group
(HOA RMS, P < .01; coma aberration RMS, P < .01;
spherical aberration RMS, P < .01; residual aberration
RMS, P .03). No signicant differences between groups
were detected in the total RMS (P .17). Signicant
correlations between contrast sensitivity and HOA RMS
were observed only in the DALK group (no glare: 3
cycles/degree, r 0.48, P .02; 6 cycles/degree:
r 0.43, P .04; 12 cycles/degree, r 0.46 and P
.03; 18 cycles/degree, r 0.40, P .05; glare: 3 cycles/
degree, r 0.41, P .05; 6 cycles/degree, r 0.47,
P .02; 12 cycles/degree, r 0.44, P .04; 18 cycles/
degree, r 0.44, P .04). We could not make a compar-
ison between the dDALK and pdDALK groups because
only 1 pdDALK patient had corneal aberrometric analysis.
CORNEAL ENDOTHELIAL DENSITY CHANGES: Figure 3
shows the endothelial cell density during the postoperative
follow-up. Before surgery, endothelial cell density was
TABLE1. Comparative Table Showing the Preoperative Data
of Patients Included in Deep Anterior Lamellar Keratoplasty
and Penetrating Keratoplasty Groups of Eyes Analyzed in
the Study
DALK Group PK Group P Value
Age (y)
Mean (SD) 29.7 (11.3) 33.0 (13.0) .40
Median (range) 28.0 (16 to 61) 31.0 (17 to 67)
Sex (male/female) 9/12 16/13 .61
UCVA (logMAR)
Mean (SD) 1.34 (0.44) 1.40 (0.46) .51
Median (range) 1.30 (0.69 to 3.00) 1.30 (0.69 to 3.00)
BCVA (logMAR)
Mean (SD) 1.30 (0.46) 1.36 (0.48) .53
Median (range) 1.30 (0.69 to 3.00) 1.30 (0.69 to 3.00)
BCVA best-corrected visual acuity; DALK deep anterior
lamellar keratoplasty; logMAR logarithm of the minimal angle
of resolution; PK penetrating keratoplasty; SD standard
deviation; UCVA uncorrected visual acuity.
The corresponding P values for the comparison between
groups are shown for each parameter evaluated.
TABLE 2. Comparative Table Showing the Postoperative
Data Conditions of Patients Included in the Deep Anterior
Lamellar Keratoplasty and Penetrating Keratoplasty Groups
of Eyes Analyzed at the Last Visit of the Follow-up
DALK Group PK Group P Value
UCVA (logMAR)
Mean (SD) 0.62 (0.27) 0.47 (0.21) .02
Median (range) 0.69 (0.15 to 1.60) 0.52 (0.00 to 1.00)
BCVA (logMAR)
Mean (SD) 0.35 (0.30) 0.23 (0.11) .13
Median (range) 0.30 (0.09 to 1.60) 0.22 (0.09 to 0.40)
BCVA best-corrected distance visual acuity; DALK deep
anterior lamellar keratoplasty; logMARlogarithmof the minimal
angle of resolution; PK penetrating keratoplasty; SD stan-
dard deviation; UCVA uncorrected visual acuity.
The corresponding P values for the comparison between
groups are shown for each parameter evaluated.
VOL. 156, NO. 2 269 DALK VS PK FOR MACULAR CORNEAL DYSTROPHY
measured in all donor corneas in the PK group; however,
endothelial cell density was obtained in 27 eyes (65.8%)
in the DALK group. The mean preoperative endothelial
cell density was 2881 6 449 cells/mm
2
and 2734 6 549
cells/mm
2
in the DALK and PK groups, respectively
(P .27). In both groups, a progressive and statistically
signicant reduction in endothelial cell density was found
during the follow-up (P < .01). Endothelial cell loss was
13.25 611.21%at 6 months, 15.44 612.31%at 12 months,
16.32 6 14.76% at 24 months, and 18.12 6 16.43% at the
last follow-up in the DALK group. In the PK group, the
mean endothelial cell loss was 12.17 6 10.92%, 15.04 6
13.21%, 22.12 618.93%, and 26.98 621.76%at 6 months,
12 months, 24 months, and the last visit, respectively.
Signicantly higher endothelial cell density loss was
observed in the PK group compared with the DALK
group at 24 months after surgery (P .03) as well as at
the last postoperative follow-up visit (P < .01). Comparing
the subgroups, the mean endothelial cell losses were not
different between the dDALK and pdDALK groups
(P > .05).
COMPLICATIONS: Microperforation occurred in 5 eyes
(14.2%) in the DALK group, and a double anterior
chamber was seen in 1 eye (2.8%) that resolved completely
after an intracameral air injection. Stromal graft rejection
episodes were seen in 3 eyes (8.5%) from the DALK group
that were treated successfully and resolved with topical
corticosteroids. In the PK group, endothelial graft rejection
episodes were seen in 5 eyes (12.1%). Two of these cases
(4.8%) resolved successfully with medical treatment,
whereas regrafting was necessary in 3 eyes (7.3%), which
was performed at 26, 33, and 35 months after the rst graft.
Furthermore, regrafting was performed in 1 eye (2.8%) in
the DALK group at 28 months because of endothelial
decompensation. In addition, 1 eye (2.4%) underwent
resuturing in the PK group because of the traumatic graft
dehiscence. Recurrence of the disease was documented in
2 eyes (5.7%) from the DALK group and also in 2 eyes
(4.8%) from the PK group. Complications are documented
in Table 4.
DISCUSSION
ALTHOUGH SUCCESSFUL OUTCOMES WITH DALK AND PK
procedures have been reported previously, histologic anal-
ysis of corneal deposits make lamellar surgery questionable
because of possible involvement of posterior corneal
tissues.
1,4,10,12
The Descemet membrane-baring techniques
suchas the Anwar big-bubble technique provide comparable
visual results with or even better than PK as conrmed in
a case-control study.
11,13
This suggests that the visual
outcomes of PK remain superior to those of DALK unless
baring of the Descemet membrane is complete. Tan and
associates also reported that techniques such as the Anwar
big-bubble technique yielded visual results that were equiv-
alent or superior to those of PK.
13
Regarding macular corneal
dystrophy, inwhichthe use of lamellar keratoplasty is a cause
of concern, no appropriate comparison between DALK and
PK has been carried out to this date. In this prospective and
randomized clinical study, we compared visual and optical
quality, effect on corneal endothelium, and surgical compli-
cations of big-bubble DALK and PK for macular corneal
dystrophy.
After surgery, UCVA and BCVA improved signicantly
in both groups. This is consistent with the results of
previous studies. Vajpayee and associates performed big-
bubble DALK in 5 cases of macular corneal dystrophy,
and BCVA improved in all cases.
14
Another DALK study
with stromal dystrophies reported a postoperative BCVA
of 20/40 or better in 75.4% of the eyes.
15
In the present
study, BCVA was 20/40 or better in 68.5% and 70.7% of
the eyes in the DALK and PK groups, respectively. This
visual outcome was found in 55% of eyes from a large series
of macular corneal dystrophy cases treated with PK.
16
Patel
and associates compared DALK and PK performed in the
TABLE 3. Comparative Table Showing the Postoperative Visual Outcomes of Patients Included in the Predesmetic Deep Anterior
Lamellar Keratoplasty and Desmetic Deep Anterior Lamellar Keratoplasty Groups of Eyes Analyzed at the Last Visit of the Follow-up
pdDALK (n 8) dDALK (n 27) P Value (MannWhitney U Test)
UCVA (logMAR)
Mean (SD) 0.72 (0.39) 0.58 (0.21) .04
Median (range) (0.52 to 1.60) 0.52 (0.15 to 1.00)
BCVA (logMAR)
Mean (SD) 0.44 (0.12) 0.32 (0.30) .05
Median (range) (0.15 to 1.60) 0.22 (0.09 to 0.40)
BCVA best-corrected distance visual acuity; dDALK desmetic deep anterior lamellar keratoplasty; logMAR logarithm of the minimal
angle of resolution; pdDALK predesmetic deep anterior lamellar keratoplasty; SDstandard deviation; UCVA uncorrected distance visual
acuity.
The corresponding P values for the comparison between groups are shown for each parameter evaluated.
270 AUGUST 2013 AMERICAN JOURNAL OF OPHTHALMOLOGY
right and left eye, respectively, of a subject with macular
corneal dystrophy.
10
These authors achieved an acceptable
bed clarity with the big-bubble technique, and controver-
sially obtained better visual outcomes with it compared
with PK in the other eye. In the current study, we also
performed subgroup analyses between dDALK and
pdDALK groups and we observed superior visual outcomes
with dDALK patients. It seems to be related to interface
problems, which is of critical importance in achieving
comparable visual outcomes to PK after DALK surgery.
Interface haze may interfere with BCVA and contrast
sensitivity because of increase in HOAs and scattering,
leading to a decrease in visual quality. Interface irregularity
was seen in 11.4% of the eyes in our DALK patients and all
of them in pdDALK group. This rate was higher than that
reported for keratoconus, whereas it was comparable with
those reported for stromal corneal dystrophies and corneal
scars undergoing DALK surgery with the big-bubble
technique.
6,9,14
Therefore, corneal surgeons must keep in
mind that DALK surgery using layer-by-layer manual
dissection may result in poorer visual outcomes than
Descemet membrane-baring techniques in macular corneal
dystrophy patients; however, larger series are needed to
evaluate this further.
Despite minimal spherocylindrical errors and excellent
uncorrected distance visual acuity after surgery, many
patients were disappointed with their vision, leading us
to believe that visual acuity measurements were not predic-
tive of visual performance in our series. For this reason, we
investigated contrast sensitivity function and corneal
HOA outcomes in each group to obtain more information
for comparing the postoperative visual performance after
both keratoplasty techniques. No signicant differences
between DALK and PK groups were obtained in mesopic
contrast sensitivity for any of the spatial frequencies evalu-
ated. This nding is consistent with those obtained in other
studies comparing the contrast sensitivity function after PK
and DALK for the management of other corneal condi-
tions.
1719
However, the results of this series contrast
with those of a previous study from our research group
comparing contrast sensitivity outcomes after DALK and
PK in keratoconus eyes, in which a signicantly better
contrast sensitivity value was obtained after DALK for
a spatial frequency of 3 cycles/degree.
20
This nding was
suggested to be in relation to the potentially smoother
interface in the periphery of DALKpatients.
20
The absence
FIGURE 1. Graph showing the mean contrast sensitivity func-
tionunder mesopic conditions measured withand without a glare
source at the last visit of the follow-up for the 2 the groups
analyzed in the study: deep anterior lamellar keratoplasty
(DALK; grey line) and penetrating keratoplasty (PK; black
line).
FIGURE 2. Bar graph showing the mean values and standard
deviations of the ocular aberrometric parameters measured
with the Zywave system in the 2 groups analyzed in the current
study: penetrating keratoplasty (PK; grey bars) and deep ante-
rior lamellar keratoplasty (DALK; white bars). The following
parameters were obatined with the aberrometer and were
analyzed for a 5-mm pupil: total root mean square (total
RMS), higher-order root mean square (HOA RMS), coma
root mean square (Coma RMS), primary spherical aberration
(SA), and residual root mean square (RMS).
FIGURE 3. Graph showing changes in corneal endothelial cell
density during the follow-up in the 2 groups analyzed in the
study: deep anterior lamellar keratoplasty (DALK; grey line),
and penetrating keratoplasty (PK; black line).
VOL. 156, NO. 2 271 DALK VS PK FOR MACULAR CORNEAL DYSTROPHY
of statistical signicance in the difference between our
DALK and PK groups may have been inuenced by the
limited sample size or the higher variability in the contrast
sensitivity outcomes observed in the DALK group. In
contrast to the contrast sensitivity outcomes of the current
series, signicant differences were observed in corneal
HOAs between PK and DALK groups. Specically,
HOA, primary coma aberration, and residual aberration
RMS as well as the coefcient corresponding to the primary
spherical aberration were signicantly higher in the DALK
group. This suggests that the aircornea interface, which is
the rst and most important refractive medium and consti-
tutes most of the total refractive power of the eye, is more
aberrated after surgery in eyes with macular corneal
dystrophy undergoing DALK surgery compared with those
undergoing PK. According to this, contrast sensitivity
outcomes also should have been poorer in the DALKgroup,
but this was not the case. One explanation for this may be
the relevant contribution of the posterior corneal surface in
these cases. Indeed, Yamaguchi and associates found in
a comparative study of anterior and posterior corneal aber-
rations after PK and DALK that posterior surfaces compen-
sated signicantly for anterior aberrations.
21
In any case,
signicant inverse correlations between HOA RMS and
mesopic contrast sensitivity were found only in our
DALK group, which conrms that this group of patients
was more susceptible to having contrast sensitivity affected
by corneal aberrations, especially in those cases with
postoperative levels of HOA.
Long-term survival of graft tissue has been linked
strongly to a sufciently high endothelial cell density.
Studies have shown that PK leads to a precipitated rate
of endothelial cell loss and a chronic loss in the endothelial
cells that has been found to contribute to graft failure in
a portion of PK procedures.
22
The median endothelial
cell density loss per year after PK was shown to be between
12% and 17%.
23,24
However in DALK, the host Descemet
membrane and endothelium are intact while only the
anterior cornea is replaced, and this results in less damage
to the endothelium with fewer immunologic reactions
and a subsequent high endothelial cell density rate after
surgery. A recent study found a 5-year postoperative endo-
thelial cell density loss of 22.3% after DALK and of 50.1%
after PK in eyes with different corneal pathologic
features.
25
In a similar study, Shimazaki and associates
prospectively compared DALK and PKover a 2-year period
and demonstrated an accelerated decrease of endothelial
cell density in the PK group.
19
In the current study with
macular corneal dystrophy, mean endothelial cell loss was
calculated as 13.2% at 6 months, 15.4% at 12 months,
16.3% at 24 months, and 18.1% at the last follow-up visit
in the DALK group. In the PK group, the percentages
were 12.1%, 15.0%, 22.1%, and 26.9% for the respective
postoperative visits. It seems that cell loss after DALK
surgery was prominent at 12 months and continues to
increase slowly during the follow-up, but this rate was
signicantly lower than that for PK grafts at 24 months
and at the last follow-up visit. It should be noted that we
performed DALK for macular corneal dystrophy excluding
endothelial opacity in our study. Endothelial decompensa-
tion needing regraft surgery developed in only 1 eye (2.8%)
in our DALK group. Similarly, Kawashima and associates
reported that 2 of 10 eyes with macular corneal dystrophy
demonstrated endothelial decompensation after anterior
lamellar surgery.
4
Despite progressive endothelial cell loss
noted in our DALK group, this rate was signicantly lower
than that of PK group. However, the risk of endothelial
decompensation should be kept in mind when evaluating
a patient with macular corneal dystrophy before surgery.
The use of optical coherence tomography to determine
a lack of endothelial involvement may be more informative
for surgeons.
Today, the success of corneal transplantation is still
dependent to a large extent on corneal graft rejection. In
a large case series of patients who underwent PK surgery
for macular corneal dystrophy, Al-Swailem and associates
demonstrated that endothelial rejection episodes occurred
in 20.5% of eyes, with irreversible endothelial failure in
3.5% of them.
16
Furthermore, 40% of the unsuccessful
corneal transplantations in this series were the result of
irreversible endothelial rejection episodes. In accordance
with these results, because of graft failure after endothelial
rejection, regrafting surgery was needed in 3 of the 5 eyes
(7.3%) from our PK group. Although DALK surgery mini-
mizes the risk of endothelial rejection, the risk of subepi-
thelial and stromal graft rejection remains.
4,9,1215
Stromal dystrophies are known to recur with in the donor
material and are expected for both the DALKand PKproce-
dure. Although the recurrence of macular corneal dystrophy
TABLE 4. Complications after Deep Anterior Lamellar
Keratoplasty and Penetrating Keratoplasty in Macular
Corneal Dystrophy
Complications DALK (n/%) PK (n/%)
Microperforation 5 (10.7) 0
Conversion to PK 6 (14.6) 0
Double anterior chamber 1 (2.8) 0
Interface irregularity 4 (11.4) 0
Elevation of IOP 1 (2.8) 2 (4.8)
Stromal graft rejection 4 (11.4) 0
Endothelial graft rejection 0 5 (12.1)
Recurrence of the disease 2 (8.5) 2 (4.8)
Secondary surgeries
Phacoemulsication 1 (2.8) 1 (2.4)
Trabeculectomy 0 1 (2.4)
Regrafting 1 (2.8) 3 (7.3)
Resuturing because of traumatic
wound dehiscence
0 1 (2.4)
DALK deep anterior lamellar keratoplasty; IOP intraocular
pressure; PK penetrating keratoplasty.
272 AUGUST 2013 AMERICAN JOURNAL OF OPHTHALMOLOGY
in patients who underwent PKhas been reported to be up to
50% in a larger follow-up period (18 years), no adequate
comparable results for DALK exist yet.
26
Unal and associ-
ates recently documented a 2.3% recurrence rate after big-
bubble DALK for macular corneal dystrophy.
15
In the
present study, recurrence of the disease was documented in
2 eyes (5.7%) from the DALK group and in 2 eyes (4.8%)
from the PK group after 30 months of follow-up. Previous
studies have shown that the recurrence rate increased in
direct proportion with the follow-up period and that there
was a subsequent need for regrafting.
26,27
We believe that
recurrence of stromal dystrophies would be comparatively
easier to manage with lamellar keratoplasty.
In conclusion, DALK with the big-bubble technique is
an alternative treatment option in eyes with macular
corneal dystrophy, providing results comparable with those
of PK. When selecting macular corneal dystrophy patients
for DALKsurgery, it is important to evaluate the possibility
of endothelial decompensation after surgery. Deep anterior
lamellar keratoplasty surgery eliminates the risk for endo-
thelial rejection with subsequent graft failure, maintains
structural integrity of the globe, and provides increased
resistance against graft trauma dehiscence. Therefore,
DALK surgery is a viable surgical option for macular
corneal dystrophy patients with no accompanying endo-
thelial involvement.
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
and none were reported. Mustafa Unal was supported by the Akdeniz University Scientic Research Projects Unit. Involved in Design and conduct of study
(E.S.S., A.K., M.U.); Collection, management, analysis, and interpretation of data (E.S.S., D.P., M.U., A.K., M.K.E., N.B.); and Preparation, review, and
approval of manuscript (E.S.S., M.U., Y.O

.). Statisticians, medical writers, AND industry writers or hidden authors did not have any role in this study.
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Biosketch
Dr Esin Sogutlu Sari was born in 1979 in Bursa, Turkey. She graduated fromIstanbul Medical Faculty of Istanbul University
and specialized in Ophthalmology in the Kartal Training and Research Hospital. Dr Sogutlu Sar is the member of Cornea
and Refractive Surgery Department in Balkseir University Medical Faculty Ophthalmology since 2012.
VOL. 156, NO. 2 274.e1 DALK VS PK FOR MACULAR CORNEAL DYSTROPHY