Lamellar Refractive Keratoplasty is a procedure that involves placing a lenticule on or within the cornea in order to alter the refractive power by changing the anterior curvature.
In this procedure, the patient’s diseased anterior corneal stroma and Bowman's membrane are replaced with donor material. The Host endothelium, Descemet's membrane and a part of the deep stroma are preserved. The donor corneal disc becomes repopulated with host fibroblasts and the recipient epithelium usually covers the anterior corneal surface. This procedure is technically more difficult than penetrating keratoplasty.
The main advantage of a Lamellar Keratoplasty is that it is primarily an extraocular procedure that preserves the host endothelium. Since this is performed outside the eye, the risk of rejection is completely diminished. Also risks associated with intraocular procedures, like, wound leaks or flat anterior chambers are eliminated.
Microsurgical techniques have greatly improved the procedure of Lamellar Keratoplasty. Because of this, use of conventional flaps and therapeutic soft contact lenses have reduced the indications for a Lamellar Keratoplasty.
When compared to a penetrating keratoplasty, this procedure has the advantage of being extraocular in most cases. Post operative management is easier with less follow-up time and less usage of immunosuppressive medications. Risks to eyes with pre-existing conditions like glaucoma or steroid sensitivity are quite minimal. If it is found that the result of a lamellar keratoplasty is not satisfactory, then a full thickness corneal grafting can be done since there is less induction of astigmatism.
Procedure
You surgeon would first, talk to you in order to understand your expectations, get to know details about your medical history and do some tests on your eyes. The most common tests include measuring corneal thickness, refraction and pupil dilation. If you wear contact lenses it is advised that you not wear them for a couple of weeks before surgery. On the day of the surgery it's recommended that you eat only a light meal.
A handheld corneal trephine is used to trephine the recipient cornea in a usual manner similar to a penetrating keratoplasty procedure. This is done to a depth of about 75 to 80% of stromal thickness. A paracenthesis is then made to drain out the aqueous and to make the eye soft. A needle is then inserted into the stroma carefully to the level just anterior to the Descemet’s membrane by observing the appearance of the fold lines. Once the needle bevel is fully buried within the substance of the stroma, air is injected until the Descemet’s membrane separates from the stromal tissue. This gives rise to the appearance of a large dome-shaped space expanding into the anterior chamber
Sometimes, air is found entering the anterior chamber possibly via the trabecular meshwork. To avoid this, a side port blade is used to make an opening into this stroma-Descemet’s membrane space. Immediately, air will be released and this space collapses. Viscoelastic solution is then injected through the same entry point to separate these two tissues planes. The anterior stroma is then excised with corneal scissors. Descemet’s membrane can be identified as a very smooth and glossy layer. The air bubble in the anterior chamber makes it easier to see this transparent layer.
The donor cornea is then punched from endothelial side up and the endothelium and Descemet’s membrane is removed. This tissue is then sutured onto the recipient bed.
Risks
Despite all of the above said benefits of a lamellar keratoplasty, a penetrating keratoplasty is still preferred for anterior corneal disorders since lamellar keratoplasty is a time consuming procedure, requires more skill and may show decreased best corrected visual activity due to scarring at the donor host interface.
Other risks include Premature loosening of sutures, ingrowth of vessels, infection or later appearance of the original disease.
Recovery
Postoperative care involves use of appropriate quantities of topical antibiotics and corticosteroids. During the few weeks the sutures are left in place. The sutures are removed when they become loose, when vessels bridge the wound from host to donor, or when healing is apparent.
The other Ophthalmology Procedures are:
The other Ophthalmology Procedures are:
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