title: Use of a novel lamellar keratoplasty with pleat technique to address the abnormal white-to-white diameter in keratoglobus.
abstract: OBJECTIVE
  We describe a novel surgical technique that seeks to address the fundamental mechanical problem of the superiorly and vertically displaced limbus and the corresponding abnormal corneal white-to-white diameter in keratoglobus.
  
  
  METHODS
  A 42-year-old woman had progressive reduction of vision due to hydrops of her right cornea with secondary peripheral corneal perforation due to progressive bilateral keratoglobus. Her visual acuity was hand movements in the right eye, with an uncorrectable refractive error. Pachymetry ranged from 287 μm in the peripheries to 474 μm centrally. The simulated keratometry average was 87 diopters. The surgical technique includes corneal debridement, paracentesis to facilitate manipulation of the cornea, cardinal compression sutures, central anterior lamellar dissection, and mattress sutures to tuck the excess peripheral cornea to create a pleat. This intralamellar tuck formed the subsequent bed to host an anterior lamellar corneal graft.
  
  
  RESULTS
  At 1-year review, the best-corrected visual acuity was 6/24 (-2.50/+2.00 ×75 in the right eye). Central corneal pachymetry was 744 μM in the right eye. The simulated keratometry average was 42.4 diopters. This visual improvement and refraction remained stable for 3 years postoperatively.
  
  
  CONCLUSIONS
  We have demonstrated a modified anterior lamellar keratoplasty with pleat technique to achieve satisfactory visual rehabilitation in extreme keratoglobus. This pleat technique addresses the fundamental structural problem of a vertically displaced limbus in keratoglobus. We highlight the optical illusion of the white-to-white diameter in keratoglobus. We also recommend the baking analogy of muffin to cupcake as a communication aid when explaining the mechanics of surgery to the patient.
authors.affiliation: Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Lockington
authors.forename: Kanna
authors.initials: K
authors.lastname: Ramaesh
mesh_terms: D000328:Adult; D003316:Corneal Diseases / Q000503:physiopathology / Q000601:surgery*; D063171:Corneal Pachymetry; D016039:Corneal Transplantation / Q000379:methods*; D004108:Dilatation, Pathologic / Q000601:surgery; D005260:Female; D006801:Humans; D012029:Refraction, Ocular / Q000502:physiology; D014786:Vision Disorders / Q000534:rehabilitation; D014792:Visual Acuity / Q000502:physiology