Secondary Logo

Institutional members access full text with Ovid®

Deep Anterior Lamellar Keratoplasty in Eyes With Intrastromal Corneal Ring Segments

Ravera, Vittoria, MD*,†; Bovone, Cristina, MD*,†; Scorcia, Vincenzo, MD†,‡; D'Angelo, Sergio, MD§; Busin, Massimo, MD*,†,¶

doi: 10.1097/ICO.0000000000001906

Purpose: To evaluate the possibility of using the intrastromal corneal ring segments (ICRSs) previously implanted as a depth reference for performing pneumatic dissection in deep anterior lamellar keratoplasty (DALK).

Methods: The depth of placement of 2 symmetrical ICRSs placed in the superior and inferior midperipheral cornea of 4 eyes of 4 patients with keratoconus was measured by means of anterior segment optical coherence tomography. Because of irregular and/or high astigmatism, DALK using pneumatic dissection was performed in all eyes. The standardized procedure included the following: 1) Deep trephination of the recipient cornea outside the ICRSs (9 mm in diameter), aimed at facilitating the insertion and advancement of a dedicated cannula under the ICRS implant, just within its peripheral margin; 2) air injection for pneumatic dissection; 3) removal of about 80% of the anterior stroma; 4) perforation of the “big bubble” ceiling under viscoelastic protection and removal of its central 6 mm; and 5) suturing of a donor lamella of the anterior stroma obtained by microkeratome dissection using a 450-μm head and punched to a diameter of 9 mm.

Results: In all cases, the site for air injection was selected where the thickness of the stroma underlying the superior ICRS did not exceed 150 μm. Pneumatic dissection succeeded uneventfully in all eyes; postoperative best spectacle-corrected visual acuity was 20/20 in 3 of 4 eyes, whereas refractive astigmatism was less than 3 diopters in all cases.

Conclusions: The presence of ICRSs facilitates gauging the depth of cannula insertion at the time of DALK, to succeed with pneumatic dissection.

*Department of Ophthalmology, Ospedali Privati Forlì, Forlì, Italy;

Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forli, Italy;

Department of Ophthalmology, University of “Magna Graecia”, Catanzaro, Italy;

Departments of §Biomedical Sciences and Specialized Surgery, and

Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.

Correspondence: Vittoria Ravera, MD, Department of Ophthalmology, Ospedali Privati Forlì, Viale Gramsci 42, 47122 Forlì, Italy (e-mail:

M. Busin receives travel expenses reimbursement from Moria (Antony, France). The remaining authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received August 30, 2018

Received in revised form January 05, 2019

Accepted January 08, 2019

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.