Deep Anterior Lamellar Keratoplasty: Different Strokes Rasik B Vajpayee, Namrata Sharma, Vishal Jhanji
Chapter Notes

Save Clear

1Evolution, Anatomy and Preoperative Evaluation2

Evolution of Deep Anterior Lamellar Corneal Transplantation1

Vishal Jhanji,
Namrata Sharma,
Rasik B Vajpayee
History of Lamellar Corneal Transplantation
Penetrating keratoplasty or full thickness corneal transplantation surgery has been the gold standard treatment for patients with corneal pathologies. The first corneal transplantation was performed by Eduard Zirm (Fig. 1.1) in 1905 and since then the surgical technique has undergone colossal advancements including those in surgical instruments and eye banking.1 However, being a full thickness procedure, penetrating keratoplasty has some inherent disadvantages, the most important being an endothelial graft rejection.
Lamellar keratoplasty (LK) was first suggested by von Walther in 1830. The idea was taken up and improved on by von Hippel (Fig. 1.2)2 in the 1880s and Filatov in the 1930s.3 In the late 1940s, Paufique further developed lamellar surgical techniques.4 As early as the 1950s, Jose Barraquer (Fig. 1.3) applied new techniques of lamellar keratoplasty, dissecting the corneal stroma down to two-thirds of its thickness in both donor and recipient tissues. The procedure failed to gain favor because of poor visual outcomes related to irregularity of the dissected surfaces and scarring in the tissue interfaces. In 1959, Hallermann tried to achieve deep preparation, approaching the Descemet's membrane (DM). He was also the first to use full-thickness corneal transplants (including the endothelium) with the aim of improving the optical outcomes of LK. McCulloch took up this suggestion and in 1963 noted that the endothelium of the graft button was rapidly lost while DM remained intact.
zoom view
Fig. 1.1: Eduard Zirm
The concept of a ‘true’ deep anterior lamellar keratoplasty (DALK) extending down to the Descemet's membrane is relatively new, and older literature does not expand on the actual depth of ‘deep’ lamellar keratoplasty.
zoom view
Fig. 1.2: von Hippel
zoom view
Fig. 1.3: Jose Barraquer
Gasset reported a series of keratoconus patients in the late 1970s who received full thickness grafts stripped of Descemet's membrane transplanted into deep lamellar beds.5 The surgery was termed ‘conectomy’, and enjoyed relatively good surgical results with 80 percent of cases achieving 20/30 or better vision, and an average astigmatism of 3.0D.
Another technique introduced as ‘full thickness lamellar keratoplasty’ involved placement of full thickness grafts, including Descemet's membrane and endothelium, into a deep lamellar bed. Histopathology of these cases showed that the presence of donor Descemet's membrane delayed wound healing in the donor Descemet's membrane–host stromal interface. This provided a rationale for stripping donor Descemet's membrane in many of the current DALK techniques introduced later.
Deep dissection under direct visual control in a potential natural cleavage plane between stroma and Descemet's membrane was first described by Anwar in 1974.6 Mohamad Anwar (Fig. 1.4) also used full-thickness donor corneal stroma but removed both endothelium and Descemet's membrane from the donor button to avoid causing an inflammatory reaction and possibly scarring and wrinkling at the interface. Although exposure of Descemet's membrane in corneal dissection was performed in the 1970s, the term “deep lamellar keratoplasty” was not employed until 1984 by Eduardo Arenas Archila, with the use of intrastromal air injection to facilitate host tissue removal.7 A similar technique was used by Price and Rostron.8,9 A few years later, Sugita published his experience with hydrodelamination and spatula delamination.10 A divide-and-conquer technique (dividing the corneal stroma into four quadrants, in two successive layers, to reach DM) was described by Tsubota. A special, semi-sharp spatula was used by Gerrit R J Melles (Fig. 1.5) to create deep lamellar dissection in a closed fashion.11 The contributions of the various investigators in this field has been highlighted (Table 1.1).
zoom view
Fig. 1.4: Mohamad Anwar
zoom view
Fig. 1.5: Gerrit R J Melles
By the late 1990s, studies indicated that DALK was associated with visual outcomes similar to PK without the risk of immunological rejection. In spite of positive reports in the literature, the classic technique of layer-by-layer stromal tissue removal was tedious and required great surgical experience, thereby limiting its use around the world. In the next few years, introduction of several new dissection techniques and the optical visualization of dissection depth during surgery provided new possibilities for the management of anterior corneal disorders.
Table 1.1   Evolution of development of deep anterior lamellar keratoplasty technique
Proposal for ‘partial’ corneal transplant
Dieffenbach (1831)
Triangular LK (sheep to human eyes)
Muehlbauer (1845)
First successful LK in humans
Arthur von Hippel (1888)
Further refinement of LK
Filatov (1930s)
Deep lamellar dissection
Jose Barraquer (1950s)
Use of full-thickness grafts in LK
Hallermann (1959)
‘True’ DALK in keratoconus (conectomy)
‘Peeling off’ technique of DALK
Malbarn (1970s)
Deep lamellar dissection
Anwar in 1972
Intrastromal air injection
‘Divide-and-conquer technique’
Tsubota (1998)
Viscoelastic-assisted LK
‘Big Bubble’ DALK
LK: Lamellar Keratoplasty; DALK: Deep Anterior Lamellar Keratoplasty
The most popular development in this field was the surgical technique “big bubble” DALK which was based on a particular way of injecting air to facilitate separation of Descemet's membrane from the corneal stroma done by Mohamad Anwar.12 The creation of an optical interface by filling the anterior chamber with air allows the surgeon to visually control the dissection depth during the entire surgery.
The introduction of DALK has renewed the interest of corneal surgeons in lamellar transplantation techniques. There have been a few useful modifications to the technique of deep anterior lamellar keratoplasty1321 in order to ease the learning curve of the surgery. The indications for performing a deep anterior lamellar keratoplasty have expanded solely from keratoconus to nearly encompass all corneal stromal disorders that spare the corneal endothelium. A recent study from the United Kingdom showed that the proportion of lamellar versus penetrating keratoplasty increased; with lamellar keratoplasty performed at the highest rates in specialist centers distributed across the country.22
There has been a substantial increase in the number of lamellar keratoplasty procedures over the past few years that have resulted in an efficient utilization of donor corneal material. Use of lamellar surgery techniques, both anterior and posterior, has enabled the corneal surgeons to use one cornea in more than one recipient.2325 This is effective in reducing donor shortage and cost in corneal transplantation surgery in the future. A recent report by the American Academy of Ophthalmology assessed the published literature on DALK and compared it with penetrating keratoplasty for the outcomes of best spectacle-corrected visual acuity, refractive error, rejection, and graft survival.26 DALK was equivalent to penetrating keratoplasty for the outcome measure of visual acuity, particularly if the surgical technique yields minimal residual host stromal thickness. There was no advantage of DALK for refractive error outcomes. DALK was superior to penetrating keratoplasty for preservation of endothelial cell density.26
DALK is a popular extraocular, corneal transplantation procedure. It has important safety advantages over penetrating keratoplasty, and is a good option for visual rehabilitation of corneal disease in patients whose endothelium is not compromised.
  1. Zirm E. Eine erfolgreiche totale keratoplastik. Arch Ophthalmol 1906;64:580–93.
  1. von Hippel A. Uber transplantation der cornea. Arch Ophthalmol 1878;24:235–56.
  1. Filatov VP. Transplantation of the cornea. Arch Ophthalmol 1935;13:321–47.
  1. Paufique L, Sourdille GP, Offret G. Les Greffes de la Cornee. Masson and Cie,  Paris:  1948.
  1. Gasset AR. Lamellar keratoplasty in the treatment of keratoconus: conectomy. Ophthalmic Surg 1979;10:26–33.
  1. Anwar M. Dissection technique in lamellar keratoplasty. Br J Ophthalmol 1972;56(9):711–3.
  1. Archila EA. Deep lamellar keratoplasty dissection of host tissue with intrastromal air injection. Cornea 1984;3:217–8.

  1. 6 Price Jr. FW Air lamellar keratoplasty. Refract Corneal Surg 1989;5(4):240–3.
  1. Chau GK, Dilly SA, Sheard CE, Rostron CK. Deep lamellar keratoplasty on air with lyophilised tissue. Br J Ophthalmol 1992;76(11):646–50.
  1. Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol 1997;81(3):184–8.
  1. Melles GR, Lander F, Rietveld FJ, Remeijer L, Beekhuis WH, Binder PS. A new surgical technique for deep stromal, anterior lamellar keratoplasty. Br J Ophthalmol 1999;83(3):327–33.
  1. Anwar M, Teichmann KD. Big-bubble technique to bare Descemet's membrane in anterior lamellar keratoplasty. J Cataract Refract Surg 2002;28(3):398–40.
  1. Sharma N, Kumar C, Mannan R, Titiyal JS, Vajpayee RB. Surgical technique of deep anterior lamellar keratoplasty in descemetoceles. Cornea 2010;29(12):1448–51.
  1. Karimian F, Feizi S. Deep anterior lamellar keratoplasty: indications, surgical techniques and complications. Middle East Afr J Ophthalmol 2010;17(1):28–37.
  1. Leccisotti A. Air-assisted manual deep anterior lamellar keratoplasty for treatment of herpetic corneal scars. Cornea 2009;28:728–31.
  1. Buzzonetti L, Laborante A, Petrocelli G. Standardized big-bubble technique in deep anterior lamellar keratoplasty assisted by the femtosecond laser. J Cataract Refract Surg 2010;36(10):1631–6.
  1. Bonci P, Della Valle V, Bonci P, Lodi R, Russo A. Deep anterior lamellar keratoplasty with dehydrated, 4°C-stored, and rehydrated lenticules. Eur J Ophthalmol 2010. pii: A93A0734-7818-4B62-BBF3-851439B0D074. [Epub ahead of print].
  1. Ramamurthi S, Ramaesh K. Surgical management of healed hydrops: a novel modification of deep anterior lamellar keratoplasty. Cornea 2011;30(2):180–3.
  1. Luengo-Gimeno F, Tan DT, Mehta JS. Evolution of deep anterior lamellar keratoplasty (DALK). Ocul Surf 2011;9(2):98–110.
  1. Sarnicola V, Toro P. Blunt Cannula for Descemetic Deep Anterior Lamellar Keratoplasty. Cornea 2011. [Epub ahead of print].
  1. Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmol 2011;118(1):209–18.
  1. Keenan TD, Carley F, Yeates D, Jones MN, Rushton S, Goldacre MJ. NHSBT Ocular Tissue Advisory Group and contributing ophthalmologists (OTAG Audit Study 8). Trends in corneal graft surgery in the UK. Br J Ophthalmol 2011;95(4):468–72. Epub 2010.
  1. Heindl LM, Riss S, Bachmann BO, Laaser K, Kruse FE, Cursiefen C. Split cornea transplantation for 2 recipients: a new strategy to reduce corneal tissue cost and shortage. Ophthalmol 2011;118(2):294–301. Epub 2010.
  1. Vajpayee RB, Sharma N, Jhanji V, Titiyal JS, Tandon R. One donor cornea for 3 recipients: a new concept for corneal transplantation surgery. Arch Ophthalmol 2007;125(4):552–4.
  1. Sharma N, Agarwal P, Titiyal JS, Kumar C, Sinha R, Vajpayee RB. Optimal Use of Donor Corneal Tissue: 1 Cornea for 2 Recipients. Cornea 2011. [Epub ahead of print].
  1. Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmol 2011;118(1):209–18.