[DALK and penetrating laser keratoplasty for advanced keratoconus]

In cases of contact lens intolerance and/or central corneal scars, corneal transplantation is indicated for advanced keratoconus. This can be performed as deep anterior lamellar keratoplasty (DALK) or as penetrating keratoplasty (PKP). The German keratoplasty registry shows that the proportion of anterior lamellar grafts in Germany has remained stable at approximately 5 % in recent years.

Up to now DALK has not been technically standardized but can result in a good visual acuity using the big bubble technique if Descemet's membrane is laid bare intraoperatively. In 10-20 % a conversion to PKP is required if perforation of Descemet's membrane occurs. In cases of advanced keratoconus PKP is still the method of first choice especially after corneal hydrops due to rupture of Descemet's membrane. Non-contact excimer laser trephination seems to be especially beneficial for eyes with iatrogenic keratectasia after LASIK and those with repeat grafts in cases of keratoconus recurrence due to the graft being too small. For donor trephination from the epithelial side, an artificial chamber is used. Wound closure is achieved by a double running cross-stitch suture according to Hoffmann. Graft size is adapted individually depending on corneal size (as large as possible and as small as necessary). Limbal centration is given priority intraoperatively due to optical displacement of the pupil.

Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient centration, reduces vertical tilt and horizontal torsion of the graft in the recipient bed, thus resulting in significantly less all-sutures-out keratometric astigmatism (2.8 D versus 5.7 D), higher regularity of the topography (SRI 0.80 vs. 0.98) and better visual acuity (0.80 vs. 0.63) in contrast to the motor trephine. The stage of the disease does not influence functional outcome after excimer laser PKP.

In cases with optimal course DALK achieves the same visual outcome as mechanical PKP but the healthy endothelium can be preserved and endothelial immune reactions are prevented in keratoconus. In contrast to the undisputed clinical advantages of excimer laser keratoplasty with orientation teeth/notches in keratoconus, the major disadvantage of femtosecond laser application is still the necessity of suction and applanation of the cone during trephination.