Long-Term Results of Deep Anterior Lamellar Keratoplasty for the Treatment of Keratoconus

PURPOSE: To evaluate the long-term endothelial cell density (ECD) changes and visual and refractive outcomes after deep anterior lamellar keratoplasty (DALK) using the big-bubble technique in eyes with keratoconus. DESIGN: Retrospective interventional case series study. METHODS: SETTING: Single hospital. PATIENTS: Two hundred forty-one eyes of 214 patients who underwent DALK for moderate to advanced keratoconus. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction, topographic astigmatism, and ECD. RESULTS: Two hundred thirty-four procedures (97%) were completed as DALK. Big bubble was successfully achieved in 193 eyes (82.4%). In 7 eyes (3%), the procedure was converted to penetrating keratoplasty because of Descemet membrane macroperforations. Microperforations occurred in 18 eyes (7.5%). The mean follow-up time was 50.5 +/- 22.2 months (range 24 to 96 months). UCVA was lower than 20/100 in all eyes preoperatively and better than 20/100 in 191 eyes (81.6%) postoperatively. BSCVA was 20/40 or better in 187 eyes (79.9%) and 20/20 or better in 38 eyes (16.2%). The mean (+/- SD) preoperative ECD that was possible in 166 eyes was 2797 +/- 561 cells/mm(2). Mean (+/- SD) endothelial cell loss was 8.1%+/- 4.6% at 1 year, 10.5%+/- 5.7% at 2 years, 15.1%+/- 14.8% at 6 years, and 22.5%+/- 15.9% at 8 years. Stromal graft rejection episodes occurred in 4 eyes, which resolved with appropriate therapy. CONCLUSIONS: Deep anterior lamellar keratoplasty that uses the big-bubble technique is effective in patients with keratoconus. Long-term endothelial cell loss was moderate and lower than penetrating keratoplasty grafts. (Am J Ophthalmol 2011;151:760-767. (C) 2011 by Elsevier Inc. All rights reserved.)