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

1
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
2
Introduction

• Penetrating keratoplasty (PK) is commonly
  performed for macular corneal dystrophy
• Traditional teaching guides against lamellar
  keratoplasty for macular dystrophy due to
• deep stroma/descemets 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

3
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

4
Case - OS

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

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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

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Outcomes

• Initial interface haze in the right (DLK) eye had
  cleared by 3 months. Off axis descemets membrane
  creases were not visually significant. Note the
  discrete residual opacities (arrow)
• BCVA at last review (18 months post-op) was 6/6
  with spectacle prescription 0.50/-1.50 x 95

Fig 1
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outcomes

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

Fig 2
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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

OD
OS
9
Discussion

• The DLK learning curve and potential newer
  complications (double anterior chamber,
  descemets 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

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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

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Conclusion

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

12
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