Penetrating Keratoplasty vs. Deep Lamellar Keratoplasty in Macular Dystrophy: Case Report Amit Patel MRCOphth, Harish Nayak MRCOphth, Vinod Kumar FRCSEd(Ophth) Princess of Wales Hospital, Bridgend, UK The authors have no financial interests with regards to this poster

Introduction Penetrating keratoplasty (PK) is commonly performed for macular corneal dystrophy Traditional teaching guides against lamellar keratoplasty for macular dystrophy due to: –deep stroma/descemet’s membrane involvement –concern about endothelial health This case describes a patient with macular dystrophy who underwent a PK in one eye and deep lamellar keratoplasty (DLK) in the fellow eye

Case A 54-year-old man presented with increasing glare and reduced vision affecting both eyes Best corrected visual acuities (BCVA) were 6/12 OU Bilateral multiple grey-white stromal opacities consistent with macular dystrophy were noted Keratoplasty was offered as driving was essential for his occupation

Case - OS Manual deep lamellar dissection (Melles’ technique) in the left eye revealed a residual hazy bed due to significant descemet’s membrane involvement The operation was thus converted to a PK (see Fig.1) Continuous suture was adjusted four months post- operatively

Case - OD The ‘Big-Bubble’ technique was used to perform lamellar dissection in the right eye The residual bed was noted to be relatively clear and the DLK completed (see Fig. 2) Continuous suture was adjusted two months post- operatively

Outcomes Initial interface haze in the right (DLK) eye had cleared by 3 months. Off axis descemet’s membrane creases were not visually significant. Note the discrete residual opacities (arrow) BCVA at last review (18 months post-op) was 6/6 with spectacle prescription: +0.50/-1.50 x 95 Fig 1

…outcomes The left graft (PK) remained clear. Note the stromal opacities in the residual host rim (arrow) BCVA at last review (24 months post-op) was 6/9+ with spectacle prescription: +3.50/-3.00 x 3 Fig 2

…outcomes Endothelial cell counts were comparable with no significant difference at 14 (OD, DLK) and 26 (OS, PK) months post-op Subjective & Objective visual acuities were better in the DLK eye ODOS

Discussion The DLK learning curve and potential newer complications (double anterior chamber, descemet’s rupture) are outweighed by the risks of ‘open sky’ surgery PK has been shown to offer faster visual recovery than DLK, although no difference in final visual- & contrast acuities has been found

…discussion Numerous advantages of DLK over PK exist: –Lower rejection rates 20% rejection rate with 3.5% failure rate has been reported in 229 cases of macular dystrophy undergoing a PK –Ease of re-grafting Up to 25% recurrence of macular dystrophy in patients with PK has been reported over 7-22 years –Lower endothelial cell loss Study comparing DLK & PK for various corneal opacities showed lower endothelial cell loss and intraocular pressure rise in the DLK group

Conclusion DLK may be a superior choice in the surgical management of macular dystrophy and should be considered when the endothelium is healthy

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