Keratokonus
Keratokonus
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
.). 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