Lamellar keratoplasty involves replacing only the diseased portion of the cornea, leaving the recipient's posterior stroma, Descemet's membrane, and endothelium intact. It is less invasive than penetrating keratoplasty. Deep lamellar endothelial keratoplasty (DLEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) specifically replace only the recipient's diseased endothelium with donor tissue. DLEK is performed through a large limbal incision while DSAEK strips off the recipient's Descemet's membrane through a small incision. Both techniques aim to provide faster visual recovery and avoid complications compared to penetrating keratoplasty.

1. Lamellar Keratoplasty

2. Introduction
• For over hundred years Penetrating keratoplasty has been the
standard care for corneal diseases
• PK involves replacing a full thickness of diseased recipient’s cornea
with that of a healthy donor cornea secured into place with 32,16 or
12 sutures
• Claesson et al studied 520 grafts, at 2 years after PK showed a visual
acuity of upto 20/40 (6/12)

3. •Why there is need
for an alternative
to PK?????

4. Because
• PKP induced astigmatism in range of 3 to 7 diopters
• Decline in endothelial cell count leading to graft failure
• Allograft rejection and endothelial decompensation were the major concerns
• Postoperative discomforts and wound healing time more
• Wound strength in lamellar graft superior
• like to cause glaucoma, cataract, Uveities Cystoid macular oedema
endophthalmities
• Graft quality , endothelium count should be good.

5. LAMELLAR KERATOPLASTY
• Involves a partial thickness of the cornea that is transplanted only on
the diseased portion, leaving the recipient posterior stroma ,
Descement’s membrane and endothelium intact.
• Less invasive procedure but involves finer surgical skill and more
refined instrumentation.

6. History
• In 1824 Reisinger performed the first animal graft and coined the
term ‘Keratoplasty’.
• The first successful lamellar keratoplasty was performed by Arthur
Von Hippel at the end of 19th century.
• Jose Barraquer was the first to perform posterior lamellar
keratoplasty in 1950

7. Indications
Optical LKP in India (Saini et al Cornea):-
• Climatic droplet keratopathy
• Infectious keratitis scarring
• Band shape keratopathy
• Herpetic Scars
• Salzmann nodular degeneration
• Lattice Corneal Dysrophy
• Traumatic corneal scars
• Aniridic keratopathy

8. Indications
Tectonic (Soong et al Cornea)
• Corneal Ulcer (Fungal
contraindicate)
• Corneal melts
• Ulcer with systemic autoimmune
diseases (RA,SLE SJ syndrome)
• Keratoconus
• Pellucid marginal degeneration
• Karatoglobus
• Terrien’s Marginal drgeneration
• Deep excision of dermoid/PTR

9. . LAMELLAR
KERATOPLASTY
Anterior
lamellar
Superficial
ALK(SALK)
Mid ALK(MALK) Deep ALK(DALK)
Posterior
lamellar
Deep Lamellar
Endothelial
Keratoplasty(DE
LK)
Descemet’s
stripping
Automated endot
helium
keratoplasty
DSAEK

10. Anterior Lamellar Keratoplasty (ALK)
• Removal and replacement of deformed or diseased anterior corneal
tissue ( epithelium, Bowman’s layer, and stroma)
• Sparing the host Descemet’s membrane and endothelium

11. Anatomy

12. Layers Thickness(um) Composition
Epithelium 50 Stratified Squamous Epithelium
Bowman’s Membrane 8-14 Compact layer of unorganised
collagen fibres Stroma
Stroma 500 Orderly arrangement of
collagen lamellae with
keratocytes
Descemet’s Membrane 10-12 Consists of basement
membrane materials
Endothelium 5 single layer of simple
squamous epithelium

14. Indications
• Indicated in corneas that have a healthy endothelium
1.Optical ALK is useful in for visual rehabilitation in patients with
• Anterior stromal scars after infectious keratitis or trauma
• Complications after refractive surgery
• Dystrophies like Reis-Buckler
• Salzmann nodular dystrophy
• Lattice, Granular, Macular dystrophy

15. Indications (contd…)
2. Tectonic ALK is useful in for re-establishing structural integrity of the cornea
• Peripheral non inflammatory thinning
• Terrin’s marginal degeneration
• Pellucid marginal degeneration
• Peripheral ulcerative autoimmune keratitis - Mooren’s ulcer.
3. Combined indications include
• Keratoconus
• Pellucid marginal degeneration
• Iatrogenic keratoectasia after Refractive surgeries

16. Surgical Planning
(Surgeon to ask themselves)
• Is the Endothelium Normal?
• What level does the pathology extend?
• Will leaving minimal posterior stroma affect visual outcome?
• Are there any issues that influence the choice of technique like
history of hydrops and break in DM that might make delamination
technique a relative contraindicate?

17. Surgical Techniques
• DIRECT DISSECTION- Partial thickness trephination
• Corneal sromal dissection with crescent
• Partial thickness donor
• Suture
• Disadvantage – Unreliable depth of dissection
Irregular Host Bed
Interface haze

18. Melles Technique
• To visualize the depth of lamellar dissection – Exchange aqueous with air-
Create Air Endothelium interface – Act as convex mirror
• A black band is visualized in front of dissecting instrument, which represent
twice the residual stroma
• Trephination
• Suture

19. ANWAR Big Bubble Technique

21. Surgical technique Anwar ‘BUBBLE’ TECHNIQUE
• The technique involves trephining the anterior host corneal surface
with a Hessburg-Barron suction trephine to a depth of about 400 µm
• 25-gauge disposable needle inserted into the corneal stroma,
• Air is then injected to create a big bubble (Anwar’s technique) that
will detach the deep stromal layers from the Descemet’s membrane.
• lamellar dissection and removal of the anterior stromal disk by
crescent knife

22. • Using a 30° superblade/15° lance tip, a small oblique incision is made
in the corneal stromal surface, releasing air and collapsing the big
bubble.
• The space between the Descemet’s membrane and the detached
deep stroma is then filled with viscoelastic.
• Utilizing a divide-and-conquer technique with corneal microscissors,
the remaining deep corneal stroma is excised to expose the smooth
surface of the Descemet’s membrane

23. • The donor cornea is then trephined with a Hessburg-Barron trephine,
followed by staining of the endothelium with trypan blue.
• Descemet’s membrane and the donor endothelium are then removed
using dry cellulose sponges and forceps.
• The donor cornea devoid of Descemet’s membrane and endothelium
is then placed within the host corneal bed and sutured in place with
16 interrupted 10-0 nylon sutures.

24. Complications Intraoperative
• Microperforation – Sudden softening eye and excursion of fluid or air into
the interface.
• Occurrence 39% expert hand
• Manage – Air in AC- Continue dissection peripheral to perforation leaving
small amount of posterior stroma- Leaving Air bubble with supine position
of patient
• Macroperforation –Convert PKP
• Pupillary Block Glaucoma- due to air bubble left in AC- Block Pupil-Angle
Closure
Avoided by Pupil dilation if air left
Periodically examination eye in hour immediately after surgery

25. COMPLICATION POSTOPERATIVE
• Double AC
Cause- Micro perforation, Entrapped Visco at interface
Manage- Accelerated intracameral Air/ SF6 and drain interface fluid
• DM Folds
• Epithelial, Subepithelial or stromal rejection
Epithelium – Line of oedema
Subepithelial- Subepithelial infiltrate
Stromal –Oedema
Management- Increase Topical steroid , systemic steroid (1mg/kg) , may
need Pulse therapy Methyl Pred IV 500mg to 1 gm/Day for 3days

26. Advantages of ALK
• less chances of postoperative inflammation as well as secondary
glaucoma.
• No risk of endothelial graft rejection.
• No need for long term steroid prophylaxis
• Rapid functional recovery of vision.
• Very good best corrected visual acuity (BCVA)
• very low astigmatism.
• No significant endothelial cell loss.
• Penetrating Keratoplasty can be done if recurrences occur or
Descemet's membrane perforation occurs intraoperatively.
• The criteria for quality of donor tissue are not very stringent

27. Deep Lamellar Endothelial Keratoplasty (DLEK)
• Purpose To remove the diseased recipient endothelium and replace with healthy
donor corneal endothelium.
• In 1998,Dr.Gerritt Melles et al first described this technique involved large limbal
incision and deep manual lamellar corneal dissection .
• Dr. Mark Terry modified by small incision 5mm rename the Procedure
“Deep Lamellar Endothelial Keratoplasty (DLEK)”
• Next Evolution by Melles was the substitution of the patient dissection with
Descement’s stripping and “Descement’s stripping Endo Keratoplasty (DSEK)”

28. •Why there is need
for DLEK ,an
alternative to
PKP?????

29. DLEK vs PKP
• DLEK procedure preserves the normal corneal topography to allow faster visual
recovery
• Astigmatism after DLEK surgery was 1.63 ±0.97D* ,
• In contrast, after standard PKP surgery was between 4.00 and 6.00D
• After DLEK surgery, endothelial cell count at 6 months was only a 22% cell loss
from preoperative donor counts.
• After PKP, the cell count has been a 34% cell loss from preoperative donor counts.
• Tectonically stable globe
• No suture related complication

30. Patients Selection
• Endothelial Diseases
Fuch’s endothelial dystrophy
Pseudophakic bullous keratopathy
Aphekic bullous keratopathy
Iridocorneal endothelial syndrome

31. DLEK

32. SURGICAL PROCEDURE LARGE INCISION
TECHNIQUE
• A scleral access incision is placed at superior limbal region of size 9.0 mm PRE
OPERATIVE APPEARANCE
• SUPERIOR LIMBAL PERITOMY
• CLEAR CORNEAL STAB INCISION
• VISCOELASTIC IN THE ANTERIOR CHAMBER (Healon is usually preferred)
• SCLERO CORNEAL LAMELLAR POCKET IS MADE USING A CRESCENT BLADE
• STRAIGHT DEVERS DISSECTOR IS THEN USED TO EXTEND THE POCKET TO MID
PUPILLARY REGION OF THE CORNEA
• THEN A CURVED DEVERS DISSECTOR EXTENDS THE POCKET COMPLETELY TO THE
LIMBUS FOR 360 DEGREES, CREATING A TOTAL AREA OF DEEP LAMELLAR POCKET

33. • THE RESECTION OF THE POSTERIOR RECIPIENT TISSUE IS DONE WITH
AN INTRASTROMAL TREPHINE (TERRY TREPHINE)
• ONCE THE BLADE IS IN POSITION IN THE POCKET, IT IS ROTATED
ALONG THE ARC OF 9.0 MM SCLERAL INCISION
• RESECTION OF THE RECIPIENTS DISK IS COMPLETED USING CINDY
SCISSORS
• ONCE THE POSTERIOR RECEIPIENT DISK HAS BEEN CUT 360 DEGREES,
THE TISSUE IS REMOVED FROM THE EYE

34. DONOR TISSUE PREPARATION
• THE DONOR CORNEOSCLERAL FLAP IS PLACED ON AN ARTIFICIAL ANTERIOR CHAMBER WHICH IS
COATED WITH HELON ON THE ENDOTHELIAL SIDE ARTIFICIAL ANTERIOR CHAMBER HEALON ON
THE ENDOTHELIUM
• THE DONOR TISSUE IS THEN CAPPED ONTO PLACE AND TREPHINATION IS CARRIED OUT TO
ABOUT 60% DEPTH
• LAMELLAR DISSECTION IS COMPLETED USING CRESCENT KNIFE THE DONOR POSTERIOR DISC IS
THEN PLACED ON A OUSLEY SPATULA
• THE DONOR DISC IS THEN SLOWLY INSERTED USING OUSLEY SPATULA
• THE SPATULA IS THEN GENTLY REMOVED FROM THE EYE LEAVING THE DONOR TISSUE BEHIND
SUPPORTED BY AIR BUBBLE IN ANTERIOR CHAMBER
• 10-0 NYLON IS THEN USED TO CLOSE THE SCLERAL WOUND AND PREVENT THE ESCAPE OF
DONOR TISSUE
• A REVERSE SINSKEY HOOK IS THEN USED FOR ENDOTHELIAL SIDE POSITIONING APPEARANCE AT
THE END OF SURGERY

35. Descemet’s Membrane Stripping Automated
Endothelial Keratoplasty (DSAEK)
• DSAEK It is a method of posterior lamellar keratoplasty in which the
recipient bed is prepared by stripping off the recipient’s Descemet's
membrane.
• Technique was popularized by Gerrit Melles in 1999

36. Indications of DSAEK
• Fuchs endothelial dystrophy (most common)
• Pseudophakic/ Aphakic bullous keratopathy
• Post PK endothelial graft rejection
• Iridocorneal endothelial syndromes (ICE)

37. DSAEK

38. SURGICAL TECHNIQUE
• RECIPIENT’S CORNEA WOUND CONSTRUCTION THROUGH A 5 MM
SCLERO CORNEAL TUNNEL
• WITH HEALON FILLING THE ANTERIOR CHAMBER DESCEMETORHEXIS
AND REMOVAL OF DESCEMET’S MEMBRANE AS A SINGLE DISK IS
CARRIED OUT USING DEXATOME
• DESCEMETORHEXIS IS BEGUN IN THE DISTAL POINT FROM THE
ANTERIOR CHAMBER ENTRY SITE AND CONTINUED IN CLOCKWISE
FASHION
• THE PERIPHERAL STROMA IS MADE ROUGH USING THE DSAEK
SCRUBBER TO ENHANCE DONOR DISK ATTACHMENT TO RECIPIENT
CORNEA

39. • DONOR CORNEAL DISK IS FOLDED INTO A ‘TACO FOLD’ AFTER PACING
A SMALL AMOUNT OF HEALON ONTO THE ENDOTHELIAL SURFACE
• DONOR CORNEAL DISK IS INTRODUCED INTO THE RECIPIENT
ANTERIOR CHAMBER AND WOUND IS CLOSED BY 3 INTERRUPTED
NYLON SUTURES
• THE DONOR DISK IS UNFOLDED USING AIR WHICH IS INJECTED IN A
CONTROLLED FASHION
• DONOR DISK IS UNIFORMLY ADHERENT TO THE PATIENT’S CORNEA

40. Complications of DSAEK
• Intraoperative conversion to PK
• Uneven recipient or donor bed thickness
• Blood in the anterior chamber
• Iris prolapse
• Fluid in the donor recipient interface
• Macrofolds
• Disk detachment during un folding
• Disc dislocation
• Graft rejection
• Late endothelial graft Failure
• Steroid induce glaucoma

41. The future of keratoplasy
• 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

42. SUTURELESS CORNEAL ADHESION
• Glue commonly use in Ophthalmology
1)Adhesive (cyanoacrylate)
2)Bioadhesive (Fibrin glue)
Kaufman et al succeddfully used fibrin glue in small series of lamellar
keratoplasty

43. Keratodesmos (PKD)
• 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 collegen molecules to produce
tight seal without thermal damage.

44. Summary

45. . LAMELLAR
KERATOPLASTY
Anterior
lamellar
Superficial
ALK(SALK)
Mid ALK(MALK) Deep ALK(DALK)
Posterior
lamellar
Deep Lamellar
Endothelial
Keratoplasty(DE
LK)
Descemet’s
stripping
Automated endot
helium
keratoplasty
DSAEK