Deep lamellar keratoplasty after resolution of hydrops in keratoconus

Deep anterior lamellar keratoplasty (DALK) using Anwar's big-bubble technique is contraindicated in cases of previous hydrops because of the risk of Descemet membrane (DM) rupture at the hydrops scar. Improved manual lamellar dissection techniques down to the deepest stromal layers now enable manual DALK surgery for previous hydrops with the possibility of obtaining good vision, as an alternative to conventional penetrating keratoplasty.

Two retrospective case reports of manual DALK in patients with previous hydrops.

A 12-year-old boy, with keratoconus and resolved hydrops in his left eye with deep stromal scarring, underwent bilateral manual DALK without baring of the DM. An intraoperative microperforation occurred in his left eye and was managed by intracameral injection of air to seal the perforation. Eleven months after his right DALK and 10 months after his left DALK, his right best spectacle-corrected visual acuity (BSCVA) was 20/20, and his left BSCVA was 20/25. The right cornea was clear, whereas the left cornea had minimal residual deep stromal scarring. Endothelial cell count by specular microscopy was 2611 cells per square millimeter in the right eye and 2193 cells per square millimeter in the left eye. A 28-year-old man, with keratoconus and resolved hydrops in his right eye with deep stromal scarring, underwent right manual DALK without baring of the DM. Nine months postoperatively, his right BSCVA was 20/30, and the graft was clear. Endothelial cell count by specular microscopy was 3148 cells per square millimeter in the right eye.

DALK can be performed in patients with previous hydrops. A controlled deep manual dissection technique without baring the DM is advocated. Good final BSCVA can be achieved despite leaving a thin residual layer of the stroma unexcised.