title: Deep Anterior Lamellar Keratoplasty After Descemet Stripping Automated Endothelial Keratoplasty.
abstract: OBJECTIVE
  To report the indications and long-term outcomes of deep anterior lamellar keratoplasty (DALK) performed after Descemet stripping automated endothelial keratoplasty (DSAEK) in cases of visually significant stromal opacities.
  
  
  METHODS
  Retrospective, interventional, consecutive case series.
  
  
  METHODS
  Setting: Private hospital.
  
  
  METHODS
  Thirteen eyes that underwent DALK after DSAEK at our institution. Indications for DALK after DSAEK included both stromal opacities persisting after DSAEK and stromal opacities occurring secondarily in post-DSAEK corneas. DALK was always performed in a standardized fashion including exchange of a disc of full-thickness recipient cornea (up to the DSAEK stromal surface),7.0 mm in diameter, with a donor lamella obtained by microkeratome-assisted dissection, punched to 7.0 mm and sutured into place with a double running 10-0 nylon suture.
  
  
  METHODS
  Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density (ECD).
  
  
  RESULTS
  Mean follow-up was 26 ± 18 months (range = 6-60 months). Indications for DSAEK were full-thickness graft failure (n = 8), DSAEK graft failure (n = 3), and pseudophakic bullous keratopathy (n = 2). Indications for subsequent DALK were persisting stromal opacity (n = 9) and stromal opacities newly occurred after DSAEK as a result of HSV keratitis (n = 2) or interface infection (n = 2). After complete suture removal, mean BSCVA was 20/28 (0.14 ± 0.8 logMAR) in eyes without ocular comorbidities affecting visual acuity (n = 7), while refractive astigmatism was within 4 diopter (D) in all but 1 eye (average = 3.2 ± 1.4 D). No intraoperative complications were recorded.
  
  
  CONCLUSIONS
  Performing DALK on DSAEK eliminates the need for open-sky surgery, achieving visual results comparable to those of penetrating keratoplasty, while sparing a healthy endothelial graft.
authors.affiliation: Department of Ophthalmology, Villa Igea Hospital, and IRFO, Istituto internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy. Electronic address: shaygut@gmail.com.
authors.forename: Shay
authors.initials: S
authors.lastname: Gutfreund
authors.affiliation: Department of Ophthalmology, Villa Igea Hospital, and IRFO, Istituto internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.
authors.forename: Pia
authors.initials: P
authors.lastname: Leon
authors.affiliation: Department of Ophthalmology, Villa Igea Hospital, and IRFO, Istituto internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.
authors.forename: Shmuel
authors.initials: S
authors.lastname: Graffi
authors.affiliation: Department of Ophthalmology, Villa Igea Hospital, and IRFO, Istituto internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Busin
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003315:Cornea / Q000000981:diagnostic imaging*; D003318:Corneal Opacity / Q000175:diagnosis / Q000601:surgery*; D057111:Descemet Stripping Endothelial Keratoplasty / Q000379:methods*; D004728:Endothelium, Corneal / Q000637:transplantation*; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D015948:Keratoplasty, Penetrating / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014792:Visual Acuity