Korean J Ophthalmol.  2015 Apr;29(2):79-85. 10.3341/kjo.2015.29.2.79.

Deep Anterior Lamellar Keratoplasty Using Irradiated Acellular Cornea with Amniotic Membrane Transplantation for Intractable Ocular Surface Diseases

• Wee SW
• Choi SU
• Kim JC

• KMID: 2363712
• DOI: http://doi.org/10.3341/kjo.2015.29.2.79

Abstract

PURPOSE
To report the clinical outcomes of deep anterior lamellar keratoplasty (DALK) when sterile gamma-irradiated acellular corneal tissues (VisionGraft) are used in combination with amniotic membrane transplantation (AMT) for intractable ocular surface diseases.
METHODS
The medical records of fifteen patients who had DALK with AMT were retrospectively reviewed. Indications for surgery included ocular burn, bacterial keratitis, herpes simplex virus keratitis, corneal opacity with Stevens-Johnson syndrome, Mooren's ulcer, idiopathic myxoid degeneration of corneal stroma, and recurrent band keratopathy. DALK was performed using partial-thickness acellular corneal tissue and a temporary amniotic membrane patch was added at the end of the operation.
RESULTS
All cases that underwent DALK with AMT became epithelialized within 2 postoperative weeks. Twelve patients showed favorable outcomes without graft rejection, corneal opacification, or neovascularization. The other three grafts developed corneal opacification and neovascularization, and required additional penetrating keratoplasty (PK). Unlike the results of previous PKs, there were no graft rejections and the graft clarity was well-maintained in these three cases for at least 8 months after PK.
CONCLUSIONS
DALK using sterile acellular corneal tissues in combination with AMT may be a good therapeutic strategy for treating intractable ocular surface diseases because of lowered immune rejection, fibroblast activation, and facilitation of epithelialization. Furthermore, DALK can help stabilize the ocular surface, prolong graft survival, and may allow better outcomes when combined with subsequent PK.

Keyword

Amniotic membrane transplantation; Deep anterior lamellar keratoplasty; Intractable ocular surface disease; Sterile acellular cornea; Visiongraft

MeSH Terms

Adult
Aged
Amnion/*transplantation
Corneal Diseases/pathology/*surgery
Corneal Stroma/radiation effects/*transplantation
Female
Graft Survival
Humans
Keratoplasty, Penetrating/*methods
Male
Middle Aged
Retrospective Studies
Visual Acuity
Young Adult

Figure

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  Fig. 1 Slit-lamp observations of the two representative patients before and after successful deep anterior lamellar keratoplasty (DALK) with amniotic membrane transplantation (AMT) (A). Patient 1: severe opacity with stromal neovascularization and almost total limbal stem cell deficiency were noted after previous failed penetrating keratoplasty. Pseudopterygium due to excessive conjunctivalization was noted in the nasal conjunctiva (B). At 12 months after DALK with AMT and pseudopterygium removal, the graft remained clear and the best-corrected visual acuity was 20 / 100 (C). Patient 4: diffuse stromal neovascularization and central corneal ulceration with whitish deposits were noted after previous failed penetrating keratoplasty. (D) At 14 months after DALK with AMT and pseudopterygium remoeval, the graft remained clear, the bestcorrected visual acuity was 20 / 50 and pseudopterygium had progressed in the nasal conjunctiva.

• 

  Fig. 2 Slit-lamp observation of the representative patient before and after failed deep anterior lamellar keratoplasty (DALK) and additional penetrating keratoplasty (PK) (A). The corneal status after multiple failed PK at an initial visit to our clinic. Stromal neovascularization, opacity, and inferior circular persistent epithelial defect were noted (arrow). Total limbal stem cell deficiency was also noted (B). At 5 months after DALK with amniotic membrane transplantation, diffuse opacity was noted on the central cornea (C). At 10 months after DALK with amniotic membrane transplantation, deep stromal ulceration with extensive vascularization and opacity had progressed to the central cornea. The authors judged graft rejection after DALK and decided to perform additional PK (D). At 8 months after additional PK, the graft remained clear and the final bestcorrected visual acuity was 20 / 50.

• 

  Fig. 3 Histological characteristics of the acellular corneal matrix in hematoxylin-eosin staining of the sterile acellular cornea; relatively loose corneal stroma with thinned epithelium showed significant acellularity when compared with the normal cornea (×100).

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