DALK preferred over PK

Chicago-Deep anterior lamellar keratoplasty (DALK) is the procedure of choice for treating patients with keratoconus and corneal scarring, according to Deepinder Dhaliwal, MD.

“We have come to a revolution in corneal transplantation and are in the era of selective keratoplasty, with only transplantation or removal of diseased corneal layers,” said Dr. Dhaliwal, associate professor, Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh.

“We do not need to do the penetrating keratoplasty (PK) of yesteryear for our patients anymore,” she said. “Endothelial keratoplasty has become the standard of care. Our patients are at a disservice if they are not offered this procedure.”

The advantages of DALK over PK are numerous, most importantly, the long-term viability of the graft endothelium; the endothelial cell count does not decrease as in PK.

In addition, there is no blinding endothelial rejection because the host Descemet’s membrane and endothelium are preserved, less steroid exposure, suture removal is earlier with DALK resulting in faster visual rehabilitation, PK can be performed later if the vision remains suboptimal, and DALK is a closed eye surgery, with the globe more stable intraoperatively and postoperatively, Dr. Dhaliwal explained.

The downsides of DALK include the potential for interface scarring and reduced visual clarity, the procedure is technically challenging, and Descemet’s membrane can be perforated.

Dr. Dhaliwal’s pearls for DALK include putting some small bubbles in the anterior chamber before injecting the big bubble.

“This is incredibly helpful to me to understand what is happening,” she said. She likes Fogla instruments, specifically, a dissector for creating a channel and a blunt cannula with the air port on the back side for insertion into the channel through which air can be injected.

She also puts a cohesive viscoelastic over the top before popping the big bubble to prevent a rapid escape of air. Viscodissection before removing the residual stroma is helpful, she noted.

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