Femtosecond Laser-Assisted Deep Lamellar Endothelial Keratoplasty: A New Approach to a Forgotten Technique

Purpose:To review indications and clinical results for a hybrid deep lamellar endothelial keratoplasty (Femto-DLEK) technique combining contemporary donor tissue preparation and implantation techniques with femtosecond laser-assisted dissection of the host tissue.Methods:A retrospective analysis of consecutive cases of Femto-DLEK performed between 2011 and 2014 at Moorfields Eye Hospital, London, was conducted. All patients underwent manifest refraction and optical coherence tomography examination at their most recent review visit. Secondary interventions, graft rejection, and graft failure were recorded alongside corrected distance visual acuity.Results:Femto-DLEK was performed in 7 eyes of 7 cases. Mean postoperative follow-up duration was 19 months. Indications included revision of deep anterior lamellar keratoplasty (n = 4), revision of failed Descemet stripping endothelial keratoplasty in cases with an anterior chamber intraocular lens (n = 2), and primary surgery in cases of dense posterior stromal copper deposition. All corneas were recorded as clear by 6 weeks after surgery. Median (range) preoperative corrected distance visual acuity was 6/60 (6/9-1/60), which improved to 6/9 (6/6-6/24) at final review. Tissue bridges requiring significant additional manual lamellar dissection were present in all 4 cases in which deep stromal femtosecond laser lamellar dissection was performed. Femtosecond laser host dissection in the remaining cases was restricted to only a posterior side-cut.Conclusions:Femto-DLEK is a useful alternative endothelial keratoplasty modality for a narrow range of indications. The femtolaser posterior side-cut facilitates DLEK, but further development of the Femto-DLEK technique is required to optimize the combination with deep lamellar host dissection.