Femtosecond-Assisted Mushroom Deep Anterior Lamellar Keratoplasty

Supplemental Digital Content is Available in the Text. Purpose:The aim of this study was to describe our technique for performing femtosecond laser (FSL)-assisted mushroom configuration in deep anterior lamellar keratoplasty (DALK).Methods:We describe our surgical technique for a mushroom-configuration DALK using a femtosecond laser (FSL) both to prepare the graft and to perform a precut of the recipient cornea, as well as the steps for the dissection of the recipient cornea and for donor cornea implantation. Moreover, we show the parameters of energy and spot separation and the external and internal diameters as well as the thickness of the external and internal keratotomy.Results:We performed a retrospective case series study of 20 patients with a mean follow-up of 4.36 +/- 2.54 years. The indication for surgery was leukoma in 15 cases (75%), keratoconus in 4 cases (20%), and stromal corneal dystrophy in 1 case (5%). Four cases had to be converted to penetrating keratoplasty. The overall results were as follows: The mean preoperative corrected distance visual acuity increased from 0.11 +/- 0.09 (0.01-0.30) to 0.78 +/- 0.22 (0.30-1.0) with spectacles and to 0.92 +/- 0.13 (0.5-1.0) with a gas permeable contact lens. The mean final cylinder was 3.90 +/- 1.86 (1.25-7.0). The mean endothelial cell count at 6 months was 2033.83 +/- 570.53 cells/mm2 (930-3207), and the mean final spherical equivalent was -4.67 +/- 2.91 (-0.25 to -9.00).Conclusions:FSL-assisted technology is useful to achieve a predictable and safe procedure when using mushroom configuration to perform DALK. Our conversion rate from DALK to penetrating keratoplasty was similar to or even lower than that reported in the literature. In the successful DALK cases, the visual and refractive results were similar to those reported in other studies using FSL-assisted DALK (with a standard or mushroom configuration).