title: Surgical technique for graft exchange after big-bubble deep anterior lamellar keratoplasty.
abstract: OBJECTIVE
  The aim of this study was to describe a surgical technique for repeat deep anterior lamellar keratoplasty (DALK) by baring Descemet membrane again in eyes affected by stromal opacity of the donor lamella.
  
  
  METHODS
  Repeat DALK was performed in 5 eyes of 5 patients affected by central stromal opacity not involving the endothelium; indications for repeat surgery were postbacterial or postherpetic corneal scars (n = 3), postphotorefractive keratectomy haze (n = 1), and recurrence of granular dystrophy (n = 1). The surgical procedure consisted of the following: (1) superficial trephination, 250 μm in depth, on the original peripheral scar; (2) blunt detachment of the donor graft completed by means of corneal forceps; (3) apposition of the new lamella. Best spectacle-corrected visual acuity, topographic astigmatism, and endothelial cell density were evaluated preoperatively, as well as 3, 6, 9, 12, and 18 months after surgery.
  
  
  RESULTS
  At the latest follow-up examination, with all sutures removed from all eyes, the best spectacle-corrected visual acuity was 20/30 or better in all cases with 3 eyes achieving 20/20. Postoperative refractive astigmatism averaged 3.0 ± 1.2 diopters (mean ± SD); endothelial cell density was not significantly affected by surgery.
  
  
  CONCLUSIONS
  Repeat DALK is effective in removing diseased corneal stroma while keeping the recipient endothelium unaffected; the procedure is simple and does not require pneumatic dissection, thus eliminating the most challenging surgical step; postoperative visual recovery does not differ from that experienced after primary DALK.
authors.affiliation: *Department of Ophthalmology, University of "Magna Graecia," Catanzaro, Italy; †Centre For Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; ‡Department of Ophthalmology, Ospedale Privato "Villa Igea," Forlì, Italy; and §Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IiRFO), Forlì, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Scorcia
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Beltz
authors.forename: Andrea
authors.initials: A
authors.lastname: Lucisano
authors.forename: Giovanni
authors.initials: G
authors.lastname: Scorcia
authors.forename: Massimo
authors.initials: M
authors.lastname: Busin
mesh_terms: D000328:Adult; D001251:Astigmatism / Q000503:physiopathology; D002452:Cell Count; D055954:Corneal Endothelial Cell Loss / Q000503:physiopathology; D003318:Corneal Opacity / Q000503:physiopathology / Q000601:surgery*; D003319:Corneal Stroma / Q000473:pathology / Q000601:surgery*; D019781:Corneal Topography; D016039:Corneal Transplantation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D014792:Visual Acuity