Penetrating Keratoplasty vs. Deep Lamellar Keratoplasty in Macular Dystrophy: Case Report

Amit Patel MRCOphth, Harish Nayak MRCOphth, Vinod Kumar FRCSEd(Ophth)

Princess of Wales Hospital, Bridgend, UK

The authors have no financial interests with regards to this poster

Introduction

• Penetrating keratoplasty (PK) is commonly performed for macular corneal dystrophy • Traditional teaching guides against lamellar keratoplasty for macular dystrophy due to: – deep stroma/descemet’s membrane involvement – concern about endothelial health • This case describes a patient with macular dystrophy who underwent a PK in one eye and deep lamellar keratoplasty (DLK) in the fellow eye

Case

• A 54-year-old man presented with increasing glare and reduced vision affecting both eyes • Best corrected visual acuities (BCVA) were 6/12 OU • Bilateral multiple grey-white stromal opacities consistent with macular dystrophy were noted • Keratoplasty was offered as driving was essential for his occupation

Case - OS

• Manual deep lamellar dissection (Melles’ technique) in the left eye revealed a residual hazy bed due to significant descemet’s membrane involvement • The operation was thus converted to a PK (see Fig.1) • Continuous suture was adjusted four months post operatively

Case - OD

• The ‘Big-Bubble’ technique was used to perform lamellar dissection in the right eye • The residual bed was noted to be relatively clear and the DLK completed (see Fig. 2) • Continuous suture was adjusted two months post operatively

Outcomes

• Initial interface haze in the right (arrow) (DLK) significant.

eye had cleared by 3 months. Off axis descemet’s membrane creases were not visually Note the discrete residual opacities • BCVA at last review (18 months post-op) was 6/6 with spectacle prescription: +0.50/-1.50 x 95 Fig 1

• The left graft (PK) remained clear. Note the stromal opacities in residual host rim (arrow) the • BCVA at last review (24 months post-op) was 6/9+ with spectacle prescription: +3.50/-3.00 x 3

…outcomes

Fig 2

OD

…outcomes

• Endothelial cell counts were comparable with no significant difference at 14 (OD, DLK) and 26 (OS, PK) months post-op • Subjective & Objective visual acuities were better in the DLK eye

OS

Discussion

• The DLK learning curve and potential newer complications (double anterior chamber, descemet’s rupture) are outweighed by the risks of ‘open sky’ surgery • PK has been shown to offer faster visual recovery than DLK, although no difference in final visual- & contrast acuities has been found

…discussion

• Numerous advantages of DLK over PK exist: – Lower rejection rates • 20% rejection rate with 3.5% failure rate has been reported in 229 cases of macular dystrophy undergoing a PK – Ease of re-grafting • Up to 25% recurrence of macular dystrophy in patients with PK has been reported over 7-22 years – Lower endothelial cell loss • Study comparing DLK & PK for various corneal opacities showed lower endothelial cell loss and intraocular pressure rise in the DLK group

Conclusion • DLK may be a superior choice in the surgical management of macular dystrophy and should be considered when the endothelium is healthy

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