가톨릭대학교 서울 성모병원 Pf.김만수/ St. 황호식/R2임성아 Video conference 가톨릭대학교 서울 성모병원 Pf.김만수/ St. 황호식/R2임성아

Introduction Lamellar keratoplasty -Partial thickness corneal donor graft Replaces only abnormal host corneal tissue. Penetrating keratoplasty -Full thickness corneal graft Replaces normal & abnormal host corneal tissue.

Introduction PKP ALK (DALK) PLK (DLEK, DSEK, DSAEK) Penetrating kertoplasy 비정상적인 ant. Cornes를 이식하는 Anterior lamellar keratoplasty 비정상적인 post corneal 즉 건강하지 못한 endothelium 을 이식하는 post keratoplsty 로 나눌수 있습니다. PLK (DLEK, DSEK, DSAEK)

Deep anterior lamellar keratoplasty Removes & Replaces the pathologic corneal epithelium & stroma Preserving host healthy endothelium 오늘 주제인 DALK 는 ant. Lamellar keratoplasty 중에서 pathologic cornea epithelium 과 deep stroma 를 제거하고, host healthy endothelium 을 보존하는 방법입니다.

Ocular surface disease Indications of DALK ** Health endothelial cell Optical Keratoconus Corneal stromal dystrophy, degeneration Deep corneal scarring ( trauma, infection) Tectonic Corneal ectasia Cornea melt(autoimmune, neurotrophic, infection) Traumatic corneal perforation, Peripheral corneal thinning Ocular surface disease SJS, Chemical or Thermal burns, Ectodermal dysplasia, Ehler-danlos syndrome 따라서 이식시 수여자를 선택할 때 health endothelial cell이 필수적인 요소입니다. DALK 의 적응 증으로는 크게 3가지로 optical cause 로 / tectonic cause /. Ocular surfaceds Cf))) Except, macular dystrophy

Deep anterior lamellar keratoplasty Extraocular procedure Not “open sky” surgery : intraoperative safety : superior wound strength Increased endothelial cell survival : low rate of acute and chronic endothelial loss : low rate of graft rejection Reduce astigmatism compared to PKP Donor tissue : Not require a healthy donor endothelium More donor corneas can be used. Dornor tissue 입장에서는 건강하지 못한 endothelium이라도 공여가능하게 되므로 더 많은 공여각막이 이식에 사용될수 있습니다.

Deep anterior lamellar keratoplasty Limitation -Technically challenging -Rough graft / host surface ->interface irregularity limits final BCVA -Longer time than PKP 제한점은 deep storoma disscction 을 위한 기술적인 어려움 각각의 graft host tissue dissection 시 surface 가 rough 하게 되면 interface irregularity 로 인해 최종 BCVA에 영향을 줄수 있습니다. “The big challenge with DALK is knowing how to go deep enough without cutting through Descemet’s membrane and making it a penetrating procedure,” “Leaving any stroma will cause scarring, so the trick is to get as close as you can without entering Descemet’s.”

Surgical procedure Recipient preparation Epithelilum & Stroma removal 2. Donor preparation DM & endothelium removal 3. Implantation for Donor button

Recipient preparation Complete dissection of recipient stroma without perforation Variety of techniques -Classic mannual dissection -Dissection with air (Anwar’s “ Big Bubble” Technique) -AC air injction (Melles' technique) -AC paracentesis Anterior chamber air injection Viscosurgical devices :Control area of dissection :Protect exposed Descemet’s membrane

Surgical procedure Cornea Trephine 2/3 depth AC paracentesis Air injection into corneal stroma Partial thickness anterior keratectomy A) The cornea trephined through two thirds of its depth with Hessburg-Barron disposable vacuum trephine After intrastromal injection of air (B) opaque swollen disc is produced (C). Dissection is started in layers with Vannas scissors, care being taken to maintain a consistent depth as far as possible (D). Divide and conquer technique is performed with diamond blade, Vannas scissors and Sinsky hook <Keratoconus (OS) 11.4.20 DALK (OS) by Pf. 김만수 >

Surgical procedure 4. Divide & Conquer Residual stroma dissection (F)After delamination with spatula G) each quarter of residual stroma was removed with Vannas scissors H) Viscoelastics injection helps to separate between residual stromal fiber and Descemet¡¯s membrane I) Exposed Descemet¡¯s membrane looks smooth and glossy membrane Removal of Descemet¡¯s membrane and endothelium from the endothelial side after full thickness grafts punched (J). The 8 bites interrupted sutures and single running suture secured the corneal button (K, L). <Keratoconus (OS) 11.4.20 DALK (OS) by Pf. 김만수 >

Surgical procedure 5. Doner-recipient corneal suture

Granular dystrophy (OU) 1987. 3. 13 Lamellar KP(OS) by Pf Granular dystrophy (OU) 1987. 3.13 Lamellar KP(OS) by Pf. 김만수 Corneal erosion(OS) 2011.05.23 DALK+Phaco +IOL sulcus ins.(OS) by Pf.김만수 상기 환자 Granular dystrophy 로 20년전 좌안 lamellar KP 시행받은자로, Corneal erosion 으로 인한 안통으로 올해 다시 DALK , IOL sulcus ins. 시행하였습니다. 이전에 lemellar KP 를 시행했던 host / recipent interface가 비교적 쉽게 dissection되었습니다. 과거에 이렇게 deep stroma dissection을 충분히 하지 않아 post stroma 가 남아있는 모습니다.

Donor preparation Donor tissue Mechanical debridement : Stripping of Descemet’s membrane punch 를 통해 얻은 donor tissue에서 DM을 strippipng 합니다. DM 을 완전하게 제거하고 regular surface를 유지하는 것이 중요합니다. DM 잘구별되지 않을때는 Trypan blue 를 사용 할 수 있습니다.

Big bubble Technique Inject air into deep stroma with 27G needle Pneumatic pressure to detach Descemet’s meb. Facilitates exposure of Descemet’s memb. *Shortens operation duration *Lower risk of perforation *Make maximum depth LKP a popular procedure 현재 big bubble technique를 이용한 maximum depth LKP 가 가장 많이 사용되고 있습니다.

AC air injection AC air injection의 방법은 AC 에 air 를 inj. 하면 mirror reflection통해 DM 과 stroma 사이의 space 가 black band 로 보여지게 됩니다. Black band 두께는 는 stroma 두께를 의미하게 되고 blunt knife가 DM 에 도달하게 되면 band 가 사라지게 됩니다. Mirror reflection : Visualization of space between DM & stroma Blunt knife is directed towards DM using the mirror reflection of air-bubble in AC as a guide

AC air injection <Keratoconus (OD) 10.3.28 DALK (OS) by Pf. 김만수 >

Surgical Complications Descemet’s memebrane perforation (Pseudoanterior chambers) Interface haze or FB Urrets-Zavalia pupil after DALK

Surgical Complications Descemet’s memebrane perforation Lattice dystrophy 11.5.23 DALK(OS) 17609096 이양순 Lattice dystrophy(OS) 11.5.23 DALK(OS) rupture stroma 박리 잘되다가 detach, donor endothelium 안긁어냄 11.6.15 Air injection(OS) R/O Lattice dystrophy (OU) 17759324 안재영 R/O Reis-Buckler dystrophy (OU) 2011.01.30 DALK(OD) by Pf.김만수 2011.03.25 AC air inj. (OD) by Pf.김만수 d/t Partially detached graft cornea(OD) 2011.3.26 AC paracentesis(OD) by St.노창래 S-J synd

11.5.23 DALK(OS) by Pf. 김만수 11.6.15 Air inj.(OS) by Pf. 김만수

Surgical Complications Descemet’s memebrane perforation Granular dystrophy 11.5.16 DALK(OS) 17609096 이양순 Lattice dystrophy(OS) 11.5.23 DALK(OS) rupture stroma 박리 잘되다가 detach, donor endothelium 안긁어냄 11.6.15 Air injection(OS) R/O Lattice dystrophy (OU) 17759324 안재영 R/O Reis-Buckler dystrophy (OU) 2011.01.30 DALK(OD) by Pf.김만수 2011.03.25 AC air inj. (OD) by Pf.김만수 d/t Partially detached graft cornea(OD) 2011.3.26 AC paracentesis(OD) by St.노창래 S-J synd

Surgical Complications Descemet’s memebrane perforation -Management depends on timing & size -Micro-perforation :managed by air inj. into AC at end of surgery -Macro-perforation :anchoring suture is required :may need conversion to PKP -Prevention : work with low IOP ↑ Risk of Double Chamber Formation = ↑ Risk of repeated A/C Air or Gas injection = ↑ Risk of endothelial damage

Surgical Complications Pseudoanterior chambers -Most Common Cx in DALK (after DM perforation) -Incomplete fusion between donor’s stroma & recipient’s endothelium -Shallow  self-limited -Surgical intervention recommended due to potential damage to the endothelium :Injection of air or gases into AC

Surgical Complications Interface haze 18629290 박용구 2008/05/03 - Lamellar KP(OD) by Prof.김만수 Inter phase scar Central corneal opacity

Surgical Complications Interface FB Granular dystrophy 11.4.15 DALK(OS) 6177617 심미영 : interface FB granular dystrophy(OS) 2011.04.15 DALK(OS) by Pf.김만수 2011.05.16 suture removal (OS) by Pf.김만수

Surgical Complications Urrets-Zavalia pupil after DALK :fixed dilated pupil with iris atrophy

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