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    5 rules to repair DALK ruptures

    While there is steep learning curve to procedure, these cases are not difficult to handle

    Worried about rupture during a deep anterior lamellar keratoplasty (DALK)? You may be overreacting.

    While rupture is the most common complication of DALK, its repair is not as difficult as commonly thought.

    A retrospective study of more than 1,000 eyes with descemet membrane (DM) ruptures during DALK found 91 ruptures. All of the ruptures were successfully repaired and there were no conversions to penetrating keratoplasty (PK).

    “There is a very difficult and steep learning curve when a surgeon begins to perform DALK,” explained Enrica Sarnicola, MD, international fellow in cornea, Cincinnati Eye Institute, Cincinnati, OH, from the Università degli Studi di Siena, Italy. “In the very beginning, it is nice to know that conversion to PK can be used as a safety net. But as soon as a surgeon becomes comfortable with DALK, he should start repairing ruptures.

    “Saving the host endothelium is the key to avoid endothelial rejection, provide a good and stable endothelial cell count, and allow for a long-term graft survival," she added.

    Ruptures happen to even the most experienced surgeons and we have seen very consistently that when they happen, repair should be the first choice.”


    DALK study

    Dr. Sarnicola discussed the results from a retrospective study of DALK, conducted by DALK surgeon Vincenzo Sarnicola, MD, Clinica degli Occhi Sarnicola, Grosseto, Italy, on 1,084 eyes of 908 patients.

    Not only were all of the DM ruptures repaired, but the rupture rate was quite low, 8.4%. DM rupture rates reported in the recent literature range from 4 to 39%, and PK conversion from 0 to 60%. Surgeon experience appears to be the best predictor of rupture risk and conversion into PK.

    Most ruptures are small micro perforations, tears in the DM that occur when the surgeon goes just a little too deep during a manual dissection. Macro perforations, ruptures larger than 2 mm, occur during the removal of residual peripheral stroma in big bubble cases.

    Of the 1,084 DALK procedures in the study, 889 were descemetic DALK (dDALK) procedures and 195 were manual DALK. There were 91 DM ruptures (8.4%) in the entire study population, of which 62 (7%) were in dDALK and 29 (15%) in manual DALK.

    Most of the ruptures (79%) were micro perforations and 21% were macro perforations. Micro ruptures were more common in both dDALK and manual DALK procedures (76% and 86%, respectively) compared with macro ruptures. Of the macro ruptures, 24% occurred in dDALK and 14% in manual DALK.

    5 rules for manual DALK ruptures

    Fred Gebhart
    The author is a correspondent for Urology Times, a sister publication.

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