**7. Conclusion**

DALK has several advantages over penetrating keratoplasty for patients with functional endothelium and a normal DM. However, many challenges tend to deter corneal surgeons from performing the procedure routinely as indicated. The advent of surgical techniques introduced by experts in corneal surgery in recent years have led to increases in DALK surgery in corneal surgical centers throughout the world. These techniques have reduced complications and the time and complexity of the procedures and increased their safety, repeatability, and efficiency. Reviewing the surgical techniques will increase our expertise in corneal surgery if we take every specific surgical "pearl" from the techniques described by experts. The expanding-bubble modification of the big-bubble technique is the one I consider most useful for routinely performing DALK surgery. I hope it will assist corneal surgeons in providing better visual results for their patients.

#### **8. Acknowledgment**

I appreciate and thank Arash Daneshgar for his technical support.

## **9. References**

74 Keratoplasties – Surgical Techniques and Complications

Fig. 23. Allograft corneal stromal rejection associated with vascularization and segmental

Epithelial allograft rejection is clinically less problematic than other types of allograft rejections. However, management includes aggressive steroid therapy to control and reverse the process. Segmental thickening of the cornea may take a long time to resolve after quiescence of the rejection process. Rarely, graft failure that requires regrafting occurs.

Great attention should be focused on the tear condition, ocular surface, and lids before a patient is scheduled for corneal transplantation. Optimization of the ocular surface by lid care, lid surgery, and fornix reconstruction before attempting a corneal graft prevents delayed epithelial healing in special cases. However, management of persistent epithelial defects includes frequent nonpreserved lubricants, reduction or cessation of application of any preserved eye drop, and bandage soft contact lens. Care must be taken to recognize herpetic corneal ulceration and to treat it appropriately. In special resistant cases tarsorraphy and punctal occlusion of inferior or both puncta works well. Application of the autologous serum augments the epithelialization of the cornea. Rare unresponsive cases

DALK has several advantages over penetrating keratoplasty for patients with functional endothelium and a normal DM. However, many challenges tend to deter corneal surgeons from performing the procedure routinely as indicated. The advent of surgical techniques introduced by experts in corneal surgery in recent years have led to increases in DALK surgery in corneal surgical centers throughout the world. These techniques have reduced complications and the time and complexity of the procedures and increased their safety, repeatability, and efficiency. Reviewing the surgical techniques will increase our expertise in corneal surgery if we take every specific surgical "pearl" from the techniques described by

may lead to stromal opacification or vascularization and require regrafting.

corneal edema.

**7. Conclusion** 

**6.9 Persistent epithelial defect** 


**5** 

*Italy*

**Femtosecond Laser Assisted** 

Luigi Mosca, Laura Guccione, Luca Mosca, Romina Fasciani and Emilio Balestrazzi

*Catholic University of "Sacro Cuore" – "A. Gemelli" Polyclinic, Rome,* 

The concept of lamellar keratoplasty (LK) is that of targeted lamellar replacement of corneal tissue while retaining normal cornea. It involves replacing anterior stroma at different deepness with an anterior lamellar keratoplasty (ALK). Despite the significant advantages of LK surgery, penetrating keratoplasty (PK) remains the most common procedure, largely because lamellar surgery is more technically demanding and time consuming 1. Moreover, interface irregularity arising from manual lamellar dissection often results in suboptimal visual outcomes 2. Long-term graft survival rates and endothelial cell counts after PK continue to drop for many years after surgery, clearly showing the disadvantage of unnecessary replacement of a healthy endothelium in anterior-stromal disorders 3. For these reasons, PK is now being replaced by various types of lamellar techniques that aim to

Recent improvements of surgical techniques and advances in instrumentation, such as microkeratome-assisted LK (ALTK) 4, and excimer laser assisted LK (ELLK), 5,6 have contributed to improve visual quality in corneal lamellar surgery, promoting a paradigm

The new femtosecond laser technology has been introduced for ophthalmic surgery in the last years with the aim to resolve the microkeratomes related problems in LASIK surgery 7. This new technology has been shown to be the "top" to perform LASIK flaps, creating flaps of precise and homogeneous thickness, reducing the flap related problems (free cap, button hole, flap irregularity) and leaving more stroma for the excimer ablation allowing to correct

Moreover, the femtolaser technology, allowing to perform precise corneal cuts with a planned and customized shape, offers clear advantages also applied in anterior lamellar

Penetrating Keratoplasty (PK) is still the most common and effective technique for corneal transplantation, but is an "open sky" surgical technique and could be complicated by choroidal effusion or haemorrage, spontaneous lens expression and vitreous loss 1. Moreover, this technique is characterized by an everlasting endothelial cell loss, leading to corneal decompensation necessitating a re-PK to restore a clear graft. To avoid these risks, more conservative surgical techniques have been proposed for the treatment of anterior corneal pathologies with healthy endothelium, enclosed in the great chapter of the lamellar keratoplasty (LK) 2, 3. So that, during the last 10 years, to increase the results of traditional

replace damaged tissue only, while maintaining healthy tissue intact.

higher refractive defects (especially with the ultrathin flaps of 90 microns).

shift in the surgical treatment of anterior corneal disease.

keratoplasty (ALK) surgery8-10.

**1. Introduction**

**Lamellar Keratoplasties** 

