Surgical technique of keratoplasty with simultaneous implantation of a continuous ring or ring segment into the graft

Kalinnikov Yu.Yu.; Kalinnikova S.Yu.; Dinh T.H.A.; Ragimova L.F.

doi:https://doi.org/10.17116/oftalma202313904171

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Abstract:

The article presents the surgical technique of penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) with femtosecond-laser assistance involving simultaneous implantation of an intracorneal continuous ring (ICCR) or an intracorneal ring segment (ICRS) into the graft. Surgical technique no. 1 — keratoplasty with simultaneous implantation of ICRS. Intrastromal circular tunnel is formed in the central zone of donor cornea using femtosecond laser. Then penetrating trepanation 8.1 mm in diameter is performed symmetrically to the formed tunnel. After preparing penetrating or lamellar recipient bed, suture fixation is placed in the corneal transplant, then the ICRS is implanted into the graft. Surgical technique no. 2 — keratoplasty with simultaneous implantation of ICCR. The donor cornea is dissected from periphery to center using femtosecond laser. Central zone remains untouched. A large diameter full-thickness trepanation is performed and the donor cornea is divided into the anterior and posterior layers. The ICCR is put on the donor cornea while holding the posterior layer with forceps. Penetrating or lamellar recipient bed is prepared, then the corneal graft is fixed with sutures. Transparent corneal graft acceptance does not guarantee high visual acuity due to post-keratoplasty astigmatism. Surgical correction of astigmatism is performed in the long term post-operatively and isn’t effective enough. We proposed this new surgical technique of keratoplasty with simultaneous implantation of ICCR and ICRS into the graft as close as possible to the visual axis of the eye, which can help make the postoperative astigmatism minimal both immediately after surgery and in the long term. The study proposes a new approach to intraoperative prevention of post-keratoplasty astigmatism. The technique is simple, safe and effective. Analysis of long-term outcomes is required before recommending this method for widespread use in clinical practice.

Keywords:

penetrating keratoplasty

deep anterior lamellar keratoplasty

intracorneal continuous ring

intracorneal ring segment

post-keratoplasty astigmatism

Authors:

Kalinnikov Yu.Yu.

A.I. Yevdokimov Moscow State University of Medicine and Dentistry;
Clinical Hospital of the Presidential Administration

ORCID: 0000-0001-7624-7163

Kalinnikova S.Yu.

The S.N. Fedorov National Medical Research Center “MNTK “Eye Microsurgery”

ORCID: 0000-0002-9109-2400

Dinh T.H.A.

A.I. Evdokimov Moscow State University of Medicine and Dentistry;
Vietnam National Eye Hospital

ORCID: 0000-0002-1774-3439

Ragimova L.F.

A.I. Yevdokimov Moscow State University of Medicine and Dentistry

ORCID: 0000-0003-3441-5434

Received:

24.03.2023

Accepted:

02.06.2023

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References:

Melles GR, Eggink FA, Lander F, Pels E, Rietveld FJ, Beekhuis WH, Binder PS. A surgical technique for posterior lamellar keratoplasty. Cornea. 1998;17(6):618-626. https://doi.org/10.1097/00003226-199811000-00010
Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006;25(8):886-889. https://doi.org/10.1097/01.ico.0000214224.90743.01
Melles GR, Ong TS, Ververs B, van der Wees J. Descemet membrane endothelial keratoplasty (DMEK). Cornea. 2006;25(8):987-990. https://doi.org/10.1097/01.ico.0000248385
Agarwal A, Dua HS, Narang P, Kumar DA, Agarwal A, Jacob S, Agarwal A, Gupta A. Pre-Descemet’s endothelial keratoplasty (PDEK). Br J Ophthalmol. 2014;98(9):1181-1185. https://doi.org/10.1136/bjophthalmol-2013-304639
Kalinnikov YuYu, Dinh THA, Zolotarevskiy AV, Kalinnikova SYu. A new surgical approach to pre-Descemet’s endothelial keratoplasty. Russian Annals of Ophthalmology = Vestnik oftal’mologii. 2023;139(1):55-66. (In Russ., In Engl.). https://doi.org/10.17116/oftalma202313901155
Archila EA. Deep lamellar keratoplasty dissection of host tissue with intrastromal air injection. Cornea. 1984;3(3):217-218.
2021 Eye banking Statistical report of Eye Bank Association of America. https://restoresight.org/wpcontent/uploads/2022/03/2021_StatisticalGuide_numbered_FINAL.pdf
Jensen AD, Maumenee AE. Refractive errors following keratoplasty. Trans Am Ophthalmol Soc. 1974;72:123-131.
Troutman RC, Gaster RN. Surgical advances and results of keratoconus. Am J Ophthalmol. 1980;90(2):131-136. https://doi.org/10.1016/s0002-9394(14)74843-3
García de Oteyza G, Borasio E, Ruíz-Santos M, Julio G, Barraquer RI, Alvarez de Toledo J. Analysis of visual and refractive results after wedge resection for high astigmatism after penetrating keratoplasty in keratoconus [published online ahead of print, 2022 Dec 20]. Eur J Ophthalmol. 2022; 11206721221144656. https://doi.org/10.1177/11206721221144656
Casimir A. Swinger. Postoperative astigmatism. Surv Ophthalmol. 1987; 31(4):219-248. https://doi.org/10.1016/0039-6257(87)90023-3
Khattak A, Nakhli FR, Al-Arfaj KM, Cheema AA. Comparison of outcomes and complications of deep anterior lamellar keratoplasty and penetrating keratoplasty performed in a large group of patients with keratoconus. Int Ophthalmol. 2018;38(3):985-992. https://doi.org/10.1007/s10792-017-0548-9
Szczotka LB, Lindsay RG. Contact lens fitting following corneal graft surgery. Clin Exp Optom. 2003;86(4):244-249. https://doi.org/10.1111/j.1444-0938.2003.tb03113.x
Feizi S, Zare M. Current approaches for management of postpenetrating keratoplasty astigmatism. J Ophthalmol. 2011;2011:708736. https://doi.org/10.1155/2011/708736
Buzard K, Haight D, Troutman R. Ruiz Procedure for Post-Keratoplasty Astigmatism. J Refract Surg. 1987;3:40-45. https://doi.org/10.3928/1081-597X-19870301-03
Cleary C, Tang M, Ahmed H, Fox M, Huang D. Beveled femtosecond laser astigmatic keratotomy for the treatment of high astigmatism post-penetrating keratoplasty. Cornea. 2013;32:54-62.
De Rosa G, Boccia R, Santamaria C, Fabbozzi L, De Rosa L, Lanza M. Customized photorefractive keratectomy to correct high ametropia after penetrating keratoplasty: A pilot study. J Optom. 2015;8(3):174-179. https://doi.org/10.1016/j.optom.2013.12.002
Bizrah M, Lin DTC, Babili A, Wirth MA, Arba-Mosquera S, Holland SP. Topography-Guided Photorefractive Keratectomy for Postkeratoplasty Astigmatism: Long-Term Outcomes. Cornea. 2021;40(1):78-87. https://doi.org/10.1097/ICO.0000000000002403
Webber SK, Lawless MA, Sutton GL, Rogers CM. LASIK for post penetrating keratoplasty astigmatism and myopia. Br J Ophthalmol. 1999;83(9): 1013-1018. https://doi.org/10.1136/bjo.83.9.1013
Malyugin BE, Tokmakova AN, Karimova AN. Otdalennye rezul’taty lazernoj korrekcii astigmatizma posle skvoznoj keratoplastiki u pacientov s keratokonusom. Prakticheskaya medicina. 2017;2(9(110)):128-132. (In Russ.).
Imamoglu S, Kaya V, Oral D, Perente I, Basarir B, Yilmaz OF. Corneal wavefront-guided customized laser in situ keratomileusis after penetrating keratoplasty. J Cataract Refract Surg. 2014;40(5):785-792. https://doi.org/10.1016/j.jcrs.2013.10.042
Hashemi H, Aghamirsalim M, Shahhoseini S, Moghaddasi A, Asgari S. SMILE after DALK to reduce residual refraction: two-year results. Int Ophthalmol. 2022;42(12):3803-3812. https://doi.org/10.1007/s10792-022-02400-8
Massoud TH, Ibrahim O, Shehata K, Abdalla MF. Small Incision Lenticule Extraction for Postkeratoplasty Myopia and Astigmatism. J Ophthalmol. 2016;2016:3686380. https://doi.org/10.1155/2016/3686380
Troutman RC. Control of corneal astigmatism in cataract and corneal surgery. Trans Pac Coast Otoophthalmol Soc Annu Meet. 1970;51:217-231.
De la Paz MF, Sibila GR, Montenegro G, et al. Wedge resection for high astigmatism after penetrating keratoplasty for keratoconus: refractive and histopathologic changes. Cornea. 2010;29(6):595-600. https://doi.org/10.1097/ICO.0b013e3181ba0abf
Böhringer D, Dineva N, Maier P, et al. Long-term follow-up of astigmatic keratotomy for corneal astigmatism after penetrating keratoplasty. Acta Ophthalmol. 2016;94(7):607-611. https://doi.org/10.1111/aos.13061
Nuijts RM, Abhilakh Missier KA, Nabar VA, Japing WJ. Artisan toric lens implantation for correction of postkeratoplasty astigmatism. Ophthalmology. 2004;111(6):1086-1094. https://doi.org/10.1016/j.ophtha.2003.09.045
Tahzib NG, Cheng YY, Nuijts RM. Three-year follow-up analysis of Artisan toric lens implantation for correction of postkeratoplasty ametropia in phakic and pseudophakic eyes. Ophthalmology. 2006;113(6):976-984. https://doi.org/10.1016/j.ophtha.2006.02.025
Wan KH, Chang JSM, Jhanji V. Toric intraocular lenses for astigmatism correction after keratoplasty in phakic and pseudophakic eyes. J Cataract Refract Surg. 2022;48(9):1078-1087. https://doi.org/10.1097/j.jcrs.0000000000000907.
Moroz ZI, Kalinnikov YuYu, Legkih SL, Ushakova AA. Surgical treatment of astigmatism after penetrating keratoplasty (preliminary results). Novoe v oftal’mologii. 2013;(2):28-30. (In Russ.).
Arriola-Villalobos P, Díaz-Valle D, Güell JL, et al. Intrastromal corneal ring segment implantation for high astigmatism after penetrating keratoplasty. J Cataract Refract Surg. 2009;35(11):1878-1884. https://doi.org/10.1016/j.jcrs.2009.05.060
Prazeres TM, Souza AC, Pereira NC, Ursulino F, Grupenmacher L, de Souza LB. Intrastromal corneal ring segment implantation by femtosecond laser for the correction of residual astigmatism after penetrating keratoplasty. Cornea. 2011;30(12):1293-1297. https://doi.org/10.1097/ICO.0b013e31821821e1
Coscarelli S, Ferrara G, Alfonso JF, et al. Intrastromal corneal ring segment implantation to correct astigmatism after penetrating keratoplasty. J Cataract Refract Surg. 2012;38(6):1006-1013. https://doi.org/10.1016/j.jcrs.2011.12.037
Lisa C, García-Fernández M, Madrid-Costa D, Torquetti L, Merayo-Lloves J, Alfonso JF. Femtosecond laser-assisted intrastromal corneal ring segment implantation for high astigmatism correction after penetrating keratoplasty. J Cataract Refract Surg. 2013;39(11):1660-1667. https://doi.org/10.1016/j.jcrs.2013.04.038
Feizi S, Javadi MA, Bineshfar N, Esfandiari H. Laser in situ keratomileusis versus Artisan lens implantation in correcting ametropia after penetrating keratoplasty for keratoconus. BMC Ophthalmol. 2023;23(1):109. https://doi.org/10.1186/s12886-023-02848-x
Yagci A, Palamar M, Barut Selver O, Yaman B. Rekeratoplasty for the Correction of Refractive Status Due to Post-LASIK Donor Graft. Exp Clin Transplant. 2022;20(3):325-327. https://doi.org/10.6002/ect.2017.0021.
Jonas JB. Femtosecond laser-assisted penetrating re-keratoplasty. Acta Ophthalmol. 2009;87(3):353-354. https://doi.org/10.1111/j.1755-3768.2008.01493.x.
Mader TH, Yuan R, Lynn MJ, Stulting RD, Wilson LA, Waring GO 3rd. Changes in keratometric astigmatism after suture removal more than one year after penetrating keratoplasty. Ophthalmology. 1993;100(1):119-127. https://doi.org/10.1016/s0161-6420(93)31705-7
Fares U, Mokashi AA, Al-Aqaba MA, Otri AM, Miri A, Dua HS. Management of postkeratoplasty astigmatism by paired arcuate incisions with compression sutures. Br J Ophthalmol. 2013;97(4):438-443. https://doi.org/10.1136/bjophthalmol-2012-302128
Feizi S, Javadi MA, Behnaz N, Fani-Hanife S, Jafarinasab MR. Effect of Suture Removal on Refraction and Graft Curvature After Deep Anterior Lamellar Keratoplasty in Patients With Keratoconus. Cornea. 2018;37(1):39-44. https://doi.org/10.1097/ICO.0000000000001443
Peng WY, Tang ZM, Lian XF, Zhou SY. Comparing the efficacy and safety of femtosecond laser-assisted vs conventional penetrating keratoplasty: a meta-analysis of comparative studies. Int Ophthalmol. 2021;41(8):2913-2923. Epub 2021 Apr 15. https://doi.org/10.1007/s10792-021-01826-w
Krumeich JH, Duncker G. Intrastromal corneal ring in penetrating keratoplasty: evidence-based update 4 years after implantation. J Cataract Refract Surg. 2006;32(6):993-998. https://doi.org/10.1016/j.jcrs.2006.02.020
Izmajlova SB, Zimina MV, Zav’yalov AS, Novikov SV, Shackih AV, Tonaeva HD, Shormaz IN, Komarova OYu. Intraoperative prevention of postkeratoplastic astigmatism using the domestic Femto Visum device in an ex vivo experiment. Prakticheskaya medicina. 2018;16(4):22-26. Accessed 18.03.23. (In Russ.). https://cyberleninka.ru/article/n/intraoperatsionnaya-profilaktika-postkeratoplasticheskogo-astigmatizma-na-otechestvennoy-ustanovke-femto-vizum-v-eksperimente-ex
Kalinnikov YuYu, Leonteva GD, Selifanov YuV, Bezzabotnov AI, Zadorozhnyj SV. Sposob provedeniya keratoplastiki (Varianty). [Method of performing keratoplasty (versions)]. Patent RF No. 2589633, 10.07.16. (In Russ.).
Anwar M, Teichmann KD. Big-bubble technique to bare Descemet’s membrane in anterior lamellar keratoplasty. J Cataract Refract Surg. 2002;28(3): 398-403. https://doi.org/10.1016/s0886-3350(01)01181-6
Riddle HK Jr, Parker DA, Price FW Jr. Management of postkeratoplasty astigmatism. Curr Opin Ophthalmol. 1998;9(4):15-28. https://doi.org/10.1097/00055735-199808000-00004.
Vail A, Gore SM, Bradley BA, Easty DL, Rogers CA, Armitate WJ. Clinical and surgical factors influencing corneal graft survival, visual acuity, and astigmatism. Corneal Transplant Follow-up Study Collaborators. Ophthalmology. 1996;103(1):41-49. https://doi.org/10.1016/s0161-6420(96)30734-3
Pecego M, Barnett M, Mannis MJ, Durbin-Johnson B. Jupiter Scleral Lenses: the UC Davis Eye Center experience. Eye Contact Lens. 2012;38(3): 179-182. https://doi.org/10.1097/ICL.0b013e31824daa5e
Tan DT, Pullum KW, Buckley RJ. Medical applications of scleral contact lenses: A retrospective analysis of 343 cases. Cornea. 1995;14(2):121-129.
van der Worp E, Bornman D, Ferreira DL, Faria-Ribeiro M, Garcia-Porta N, González-Meijome JM. Modern scleral contact lenses: A review. Cont Lens Anterior Eye. 2014;37(4):240-250. https://doi.org/10.1016/j.clae.2014.02.002
Krumeich JH, Daniel J. Perforating keratoplasty with an intracorneal ring. Cornea. 1999;18(3):277-281. https://doi.org/10.1097/00003226-199905000-00006
Izmajlova SB, Maljugin BE, Novikov SV, et al. Sposob provedeniya keratoplastiki s odnomomentnoj implantaciej intrastromal’nogo kol’ca dlya profilaktiki posleoperacionnogo astigmatizma [A method of conducting keratoplasty with simultaneous implantation of an intrastromal ring for the prevention of postoperative astigmatism]. Patent RF No. 2674889, 13.12.18. (In Russ.).
Blavatskaya ED. Refrakcionnaya keratoplastika [Refractive keratoplasty]. Erevan: Ajastan; 1973. (In Russ.).