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Deep Trephination Allows High Rates of Successful Pneumatic Dissection for DALK Independent of Surgical Experience

Myerscough, James, FRCOphth*,†; Bovone, Cristina, MD*,‡; Scorcia, Vincenzo, MD*,§; Ricci-Filipovic, Benedetta, MD*,‡; Leon, Pia, MD*,‡,¶; Mimouni, Michael, MD; Nahum, Yoav, MD**,††; Busin, Massimo, MD*,‡,‡‡

doi: 10.1097/ICO.0000000000001881

Purpose: To evaluate the relationship between surgical experience and the success rate of pneumatic dissection for deep anterior lamellar keratoplasty (DALK) using deep trephination.

Methods: A noncomparative case series evaluating the first 10 consecutive keratoconic eyes without deep stromal scarring, operated by 8 surgeons of 3 different experience levels, was conducted; there were a total of 80 patients. Standardized DALK was performed, including deep trephination 450 to 550 μm in depth and 9 mm in diameter, pneumatic dissection, removal of the stroma, and transplantation of a 9-mm partial-thickness anterior lamellar graft. The success rate of pneumatic dissection correlated with surgical experience.

Results: Pneumatic dissection succeeded in 7, 7, 8, and 9 cases of 10 cases in the first group of 4 inexperienced surgeons (under 10 previous keratoplasties of any kind); in 9 and 10 of 10 cases in the second group of 2 relatively experienced surgeons (under 100 keratoplasties); and in 10 and 8 of 10 cases in the third group of 2 very experienced surgeons (more than 1000 previous keratoplasties). No difference between the groups was found to be statistically significant with the χ2 test (P > 0.05).

Conclusions: The standardized DALK technique using a deep trephination allows high success rates of pneumatic dissection even for surgeons inexperienced in keratoplasty.

*Department of Ophthalmology, Ospedale Privato “Villa Igea”, Forlì, Italy;

Southend University Hospital, Southend, United Kingdom;

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

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

Department of Ophthalmology, Ospedale “SS. Giovanni e Paolo,” Venezia, Italy;

Department of Ophthalmology, Rambam Health Care Campus and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel;

**Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel;

††Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and

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

Correspondence: Massimo Busin, MD, Department of Ophthalmology, OspedalePrivato “Villa Igea”, 47122 Forlì, Italy 419566 (e-mail:

M. Busin has received (2006–2016) reimbursement of travel expenses and royalties from Moria (Antony, France). The remaining authors have no conflicts of interest to disclose.

Presented in part as a poster at the Annual Meeting of the American Academy of Ophthalmology; 11–14 November, 2017; New Orleans, LA.

Received October 15, 2018

Received in revised form December 10, 2018

Accepted December 15, 2018

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