DALK

(DEEP ANTERIOR LAMELLAR KERATOPLASTY)

Moderator- Dr.John Sarkar

Presenter- Dr.Sirisha Rampilla
 CLASSIFICATION

LAMELLAR KERATOPLASTY

ANTERIOR LAMELLAR POSTERIOR LAMELLAR

KERATOPLASTY KERATOPLASTY

Descemet’s
Superficial Deep stripping Descemet Deep
anterior anterior endothelial membrane lamellar
lamellar lamellar keratoplasty endothelial endothelial
keratoplasty keratoplasty (DSEK) keratoplasty keratoplasty
(SALK) (DALK) (DMEK) (DLEK)
(DSAEK)
 Why lamellar keratoplasty??

Loose suture can induce

Unpredictable post op epithelial breakdown, Long post operative visual
astigmatism ulceration, infection, recovery
vascularisation .

corneal wound relatively

Dramatic shift in corneal
fragile, with poor tectonic Increased risk of all open
topography can occur
strength, making eye sky procedure like RD,
following suture removal
susceptible to minor trauma expulsive choroidal
resulting in irregular
even several years following haemorrage.
astigmatism
surgery
 ANATOMY
LAYERS THICKNESS(µm) COMPOSITION

Epithelium 50 Stratified squamous

Bowman’s membrane 8-14 Compact layer of

unorganized collagen fiber
Stroma 500 Orderly arranged collagen
lamellae with keratocyte
Dua’s layer 10-15 Consists of typ 1 collagen

Descemet’s membrane 8-10 Consist of basement

membrane
Endothelium 5 Single layer of simple
squamous epithelium
SURGICAL ANATOMY OF STROMA
 Thickness of Collagen fibrils in Ant. 1/3 Post 2/3

stroma- 478-500 Orientation to oblique parallel

corneal surface
microns arrangement Branching present Less loosely placed
lamella interweave
 The deeper in the
stroma the surgeon
is, the easier it is to
dissect between the
lamellae
 i.e Easier to do LK,
The deeper we go
• ADVANTAGE
I. Non-penetrating surgery
II. Reduced risk of
endothelial graft rejection
III. Does not require good
endothelial quality donor
tissue
IV. Technically achieves a
stronger corneal wound
V. Suture related astigmatism
is lesser
• DISADVANTAGE
I. Technically more demanding
and time consuming
II. Suboptimal visual acuity
compared to PK due to
 Interface problems
 Lamellar dissection
regularity
 Residual scarring
 OPTICAL ALK- FOR VISUAL
REHABILITATION

Congenital dermoid Post chem. scar Post trauma scar

Healed SPKS Band keratopathy Salzmann nodule

TECTONIC ALK- FOR RE-ESTABLISHING
STRUCTURAL INTEGRITY OF THE CORNEA

Pellucid marginal
Mooren’s ulcer
degeneration

Terrin’s marginal degeneration

 THERAPEUTIC – TO ELIMINATE
CORNEAL INFECTION

MICROBIAL KERATITIS
optical + tectonic ALK
ANTERIOR LAMELLAR
KERATOPLASTY
Superficial Anterior Deep Anterior Lamellar
Lamellar Keratoplasty (DALK)
Keratoplasty (SALK) • corneal stroma is completely
excised up to DM
• anterior 30 to 50% of
• stroma-to-DM interface
cornea
provides higher quality
• stroma-to-stroma vision
interfaces can degrade
visual acuity over time
 Slit lamp: depth
of stroma
involved

Lid and adnexa,

tear
film,infection/i
Anterior Preoperative nflammation,
segment
OCT assessment posterior
segment, IOP,
general
systemic exam

Pachymetry
 Surgical technique
Globe exposure

Host cornea marking: optical axis is marked using gentian violet

marking pen.
Stained 8 or 12 prong radial marker used to aid in suture placement

Sizing & trephination: size of opacity measured with measuring caliper

Trephine is preset to requisite depth in accordance with depth of stromal
involvement
Partial thickness trephination of host cornea is done

Stromal dissection types:

1.Manual
2. automated
 1.MANUAL DISSECTION

• CLOSED DISSECTION-

After desired depth trephination, stromal pocket is made with

paufique knife at incision site

Introduce lamellar dissector through the pocket while lifting up the

anterior lip of the flap

Dissection continued by gentle side to side movement and parallel to

posterior stroma

Smoother preparation but no direct visualisation possible

 OPEN DISSECTION

• Here the edge of the separated anterior lamellar tissue is held retracted with the help of
forceps during the dissection enabling direct visualization of the area of separation.

2.AUTOMATED LAMELLAR KERATOPLASTY-

• Microkeratome used Allows for superior smooth surface
• Not suitable for thin & irregular corneas as in advanced keratoconus

Indications:
• Stromal lesions limited to anterior stromal layers
• Moderate keratoconus
• Post PRK haze
 IN DALK

• Entire corneal stroma is removed baring the Descemet’s membrane .

Adv –
• elimination of the graft host stromal interface, scarring, irregularity
• Various methods used to seperate DM from stroma-
1. Air dissection- ANWAR BIG BUBBLE TECHNIQUE most commonly used
2. Viscodissection –
3. Hydrodelamination –saline solution is used
• Careful manual peeling using tryphan blue for better
visualization of DM in donor cornea
• clevage plane should be between banded and non banded part of
DM in recipient preparation
• Hydrodelamination has 39% chance of perforation
• Air dissection has 9% chance of perforation
ANWAR BIG BUBBLE
TECHNIQUE
 DONOR CORNEA

• The donor tissue is prepared by

punching an appropriate sized CS button
with a trephine.
• Trypan blue can be used to stain the
endothelium to improve visualization in
order to facilitate the removal to DM
and endothelium from donor tissue.
• Donor tissue is then sutured with host
tissue using 10-0 nylon sutures in a
contineuos or interrupted fashion.
 INTRAOP COMPLICATION
• Descemet membrane perforation-
 Microperforation –self sealing or inject air to AC
 Large perforation from rim to rim- suture (10-0 nylon)it with donor stroma.
If not possible convert it to PK

• Pseudoanterior chamber-
 Due to occult break
 Due to retained visco
 Treatment-
 Shallow double chamber-self limiting, resolve in few week, long standing
one required surgical intervention by injecting air to AC

• Irregular lamellar bed-

 Causes astigmatism, significant interface haze
 Can be avoided by big bubble technique or automated microkeratome
assisted anterior lamellar keratoplasty
• Graft-host malapposition/edge irregularity-
 due to improper sizing of tissue
 Adopt hemi-automated anterior lamellar procedure in which the
trephine is used to cut grafts of appropriate size after the donor
automated cuts on the donor cornea and the host corneal lamellar
dissection is performed manually.

• Interface debris-
 due to fibers, bleeding
 Wash thoroughly after procedure
 POST OP COMPLICATION

• Persistent epithelial defect

• Infection: Graft infection due to various causes such as suture related,
lid adnexal abnormalities, poor ocular surface, prolonged topical steroid,
poor hygiene

• Recurrence of the primary pathology- ex HSV, corneal dystrophy

• Graft Rejection- less common
• Graft vascularization-can be seen in ocular surface pathologies such as
trachomatous keratopathy, chemical burns and Stevens-Johnson
syndrome.
 RECENT ADVANCES
FEMTOSECOND LASER DSAEK •
• This laser is used to create flaps in LASIK and can be used to
perform keratoplasty with different shapes of stromal cut.
• The laser uses an infrared wavelength (1053nm) to deliver
closely spaced, 3 microns spots that can be focused to a preset
depth to photodisrupt the tissue within the corneal stroma.
• Femtosecond laser is used to create a dissection plane on the
donor cornea mounted on artificial anterior chamber.
• Offers a potential advantage over microkeratome with regards
to
 better sizing of the posterior lenticule.
 Obtains a smooth surface and precise stromal cuts
SUTURELESS CORNEAL
ADHESION
• Bioadhesive (Fibrin glue)- Kaufman et al successfully used
fibrin glue in small series of lamellar keratoplasty

• Photochemical keratodesmos is method of producing

sutureless adhesion by applying a photosensitizer to wound
surfaces followed by low energy laser irradiation. Laser
promotes cross linkage between collagen molecules to produce
tight seal without thermal damage
Thank
you