title: Indications and outcomes of deep anterior lamellar keratoplasty in children.
abstract: OBJECTIVE
  To report our experience of deep anterior lamellar keratoplasty (DALK) in children.
  
  
  METHODS
  Retrospective case note review.
  
  
  METHODS
  Nine patients (13 eyes) aged from 13 weeks to 14 years, 11 months at the Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children National Health Service (NHS) Trust, London, United Kingdom.
  
  
  METHODS
  A study of all pediatric patients undergoing DALK from February 2002 to October 2008 was undertaken. Deep anterior lamellar keratoplasty was attempted in 9 children (13 eyes); the procedure was successful in 11 eyes, and 2 eyes progressed to penetrating keratoplasty (PKP). One eye underwent repeat DALK. Preoperative examination included electrophysiology, ultrasound biomicroscopy (UBM), and slit-lamp biomicroscopy.
  
  
  METHODS
  Complications and visual acuity at last follow-up.
  
  
  RESULTS
  Five patients had mucopolysaccharidoses (MPS), 3 patients had scarring presumed to be infectious, and 1 patient had keratoconus. Because of the failure of follow-up and loose sutures, 1 child with MPS had an epithelial rejection and the operation was repeated successfully. All grafts showed good graft clarity 10 to 80 months after grafting with visual acuities ranging from 0.28 to 1.0 logarithm of the minimum angle of resolution. Two children with nonspecific causes of scarring showed good visual acuities 24 to 51 months post-DALK. Two children who had conversion to PKP were lost to follow-up because they had moved abroad. In 4 of the 5 children with MPS, established techniques of DALK could not be performed because of excessive glycosaminoglycans (GAGs) in the stroma. Ultrasound biomicroscopy was used to guide trephination depth in the first instance. In 1 child with MPS, viscodissection was successfully used. All clinically diagnosed scars were histologically confirmed, and electron microscopy of corneal buttons confirmed the diagnosis in patients with MPS.
  
  
  CONCLUSIONS
  Deep anterior lamellar keratoplasty should be considered in children with MPS and partial-thickness scars. In MPS, viscodissection and the "big bubble" technique may not be useful if there are excessive GAGs in the stroma.
  
  
  BACKGROUND
  Proprietary or commercial disclosure may be found after the references.
authors.affiliation: Clinical and Academic Department of Ophthalmology, Great Ormond St Hospital for Children, London, United Kingdom.
authors.forename: Samantha A
authors.initials: SA
authors.lastname: Harding
authors.forename: Ken K
authors.initials: KK
authors.lastname: Nischal
authors.forename: Anjali
authors.initials: A
authors.lastname: Upponi-Patil
authors.forename: Darren J
authors.initials: DJ
authors.lastname: Fowler
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003316:Corneal Diseases / Q000175:diagnosis / Q000601:surgery*; D016039:Corneal Transplantation; D004594:Electrophysiology; D015817:Eye Infections / Q000175:diagnosis / Q000601:surgery; D005260:Female; D006801:Humans; D007223:Infant; D007640:Keratoconus / Q000175:diagnosis / Q000601:surgery; D015948:Keratoplasty, Penetrating; D008297:Male; D033401:Microscopy, Acoustic; D009083:Mucopolysaccharidoses / Q000175:diagnosis / Q000601:surgery; D011182:Postoperative Care; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome; D014792:Visual Acuity / Q000502:physiology