**2.1 Clinical experience with Femto-ALK**

The experience performing Anterior Lamellar Keratoplasty (ALK) for different corneal pathologies starts in May 2005, first with a 15 kHz (10 cases) and then with a 60kHz (11 cases) femtosecond laser (IntraLase, AMO, USA). From July 2005 to December 2007 has been performed 21 consecutive femtolaser-assisted ALK (Femto-ALK) procedures for different corneal pathologies (5 post-traumatic corneal scar, 3 post-keratitis corneal leucoma, and 13 moderate keratoconus).

#### **2.2 Femtosecond laser features**

78 Keratoplasties – Surgical Techniques and Complications

manual ALK, the use of high technologic tools such as microkeratomes or excimer lasers

With the aim to realize a more safe, repeatable and effective LK technique, suitable to every surgical skills, in 2005 we started to use the femtosecond laser technology (IntraLase, AMO, USA) (Figure 1,2) in several cases of anterior corneal pathologies (Femtolaser-assisted Anterior Lamellar Keratoplasty – Femto-ALK -. Early data published on Cornea in 2008) 9. With the diffusion of the new manual techniques of DALK, especially the "Big Bubble" one11-15, allowing the better visual results ever reached by a ALK, the Femto-ALK technique resulted quite inadequate. For these reasons, we developed a more effective femtolaser assisted lamellar technique: the Femtolaser-assisted Deep Anterior Lamellar Keratoplasty (Femto-DALK). Below the description of our Femtolaser-assisted LK techniques and the

with customized ablation patterns has been proposed, with uncertain outcomes 4-6.

results reached after more than two years of follow-up with these two techniques.

Fig. 1. The femtosecond laser (IntraLase, AMO, USA) settled near the excimer laser (Technolas 217C, Bausch & Lomb, USA) in the Laser Room of the Ophthalmic Department

In 2008 we published our first data on femtolaser-assisted ALK after one year of follow-up 9. The technique of femtolaser-assisted ALK reaches modest results, with slight patient's dissatisfaction in the first months after surgery, even if after complete suture removal the visual acuity resulted drastically growing up (Figure 3). Nevertheless, these initial results were not validated by a longer follow-up. Below, we present the clinical results more than

The experience performing Anterior Lamellar Keratoplasty (ALK) for different corneal pathologies starts in May 2005, first with a 15 kHz (10 cases) and then with a 60kHz (11 cases) femtosecond laser (IntraLase, AMO, USA). From July 2005 to December 2007 has been performed 21 consecutive femtolaser-assisted ALK (Femto-ALK) procedures for different

of Catholic University of " Sacro Cuore" of Rome, Italy.

**2. Anterior Lamellar Keratoplasty (ALK)** 

**2.1 Clinical experience with Femto-ALK** 

three years postoperatively.

The femtosecond laser of the Ophthalmic Department of Catholic University of "Sacro Cuore" (Figure 1) features are as follows: spot size of < 3µm, repetition rate of 60 kHz (for the first 10 patients the repetition rate was 15kHz); laser pulse duration of 600-800 fs (±50); maximum laser pulse peak power of 12 MW (±2); central laser wavelength of 1053nm; maximum pulse energy of 7.3 mJ (±0.7); maximum laser beam output of 110mW (±11). The laser acts with four different ablation patterns (Raster, double raster, spiral and pocket) that can be mixed by the surgeon for the surgical target. The femtosecond laser pulses result in multiple corneal intrastromal gas bubbles (micro-cavitations), requiring only a manual light lamellar dissection using a blunted spatula, to create the intrastromal cut with a smooth surface.
