Femtosecond Laser–Assisted Sutureless Anterior Lamellar Keratoplasty Einollahi MD Shahid behshti ophthalmic excellence www.iranophthalex.com

Minimizes potential intraoperative Complications Anterior LK provides several advantages over conventional full-thickness keratoplasty Minimizes potential intraoperative Complications Faster visual and refractive recovery Maintaining the recipient endothelial layer decreases the rate of graft rejection perform multiple lamellar (anterior, stromal, posterior– endothelial) corneal transplantations from one donor’s cornea

Anterior lamellar kerato plasty (ALK) Is a partial-thickness corneal transplantation used in eyes with pathology limited to the anterior layers Superficial corneal scars after Trauma keratitis epithelial/ anterior stromal dystrophies

Anterior stromal dystrophies

The major limitations with anterior LK are the technical challenges Difficult to performing manual dissections The resulting stromal interface irregularities between the donor and recipient interface stromal interface haze Induced irregular astigmatism Loss of (BCVA)

Recent procedure to minimize ALK difficulties The improvements in automated micro keratomes and artificial anterior chambers (ALTK) Femtosecond Laser–Assisted Sutureless Anterior Lamellar Keratoplasty

Sutureless femtosecond Laser–Assisted Anterior Lamellar Keratoplasty(FALK) Highly reproducible dimensions of the cuts at the graft– host junction Accurate the shape and corneal dimensions of the donor and recipient safe Efficient

Sutureless FALK The high precision and reproducibility of femtosecond A smoother donor– host interface Less induced Irregular astigmatism and Interface haze Faster and better wound healing, without the need for sutures Excimer laser in the PTK mode successfully treat superficial corneal opacities or refractory error in Bed

Reduced incidence of flap complications The main advantages of femtosecond laser over mechanical microkeratome are Reduced incidence of flap complications Greater surgeon choice of flap diameter and thickness, side cut angle, hinge position, and length A more regular corneal surface can create flaps as thin as 90 mm

FALK superior than PTK

Sutureless FALK Surgical Technique Performed Anterior segment ocular coherence tomography OCT before surgery Performed under topical anesthesia Create the donor graft with femtosecond Laser from donor globe

Corneal OCT

Sutureless FALK Surgical Technique… The lenticule adjusted in relation to depth of the lesions according to the anterior segment OCT findings Depending on the donor tissue quality and edema, additional thickness was added to the donor lenticule to adjust for donor tissue swelling A recipient corneal lenticule was created using similar femtosecond laser or 0.1 mm smaller

Sutureless FALK Surgical Technique After the procedure, the patient was transferred to the surgery room, where the corneal button was removed with a blunt spatula leaving the clear stromal residual bed The keratectomy incision was dried with methylcellulose sponges After approximately 5 minutes (to dehydrate the cornea and improve adhesion A bandage contact lens was fitted over the cornea

Post operation Patients were then placed on a topical antibiotic and steroid for 1 week, and steroid drops were slowly tapered over several months A bandage contact lens removed over the cornea after 2 weeks

Sutureless FALK Surgical Technique Femtosecond laser energy adjustments should be considered Patients with severe corneal scars totally obscuring visualization of anterior segment structures were excluded because of concern that the scars’ opacification could scatter laser energy

Complications Residual corneal scarring Residual deposits Anisometropia Dry eye Graft dislocation graft rejection Infection Epithelial ingrowth

Epithelial ingrowth

Suture less FALK Surgical Technique

Suture less FALK Surgical Technique Pre OP Post OP