Eye-2015 Baltimore, USA July13 - 15 2015 Didar S Anwar

DIDAR S. ANWAR, MD HAWLER MEDICAL UNIVERSITY BLUNT SCISSORS DISSECTION FOR DEEP ANTERIOR LAMELLAR KERATOPLASTY AFTER FAILED BIG-BUBBLE TECHNIQUE DIDAR S. ANWAR, MD HAWLER MEDICAL UNIVERSITY Eye Disorders and Treatment July 13-15, 2015 Baltimore, USA

Recently Anwar’s big-bubble DALK became a popular technique.2 Developed by Dr. Anwar in 2002 Leave minimum residual stroma therfore decreases interface problems. 2. Anwar, Mohammed and etal “Big-bubble technique to bare descemet’s membrane in anterior lamellar keratoplasty” Journal of Cataract & Refractive Surgery , Volume 28 , Issue 3 , 398 - 403

Why DALK ? DALK has less endothelial rejection rate1 DALK has less endothelial cell loss1 DALK has longer survival rate1 1. Liu, Hao et al. “Efficacy and Safety of Deep Anterior Lamellar Keratoplasty vs. Penetrating Keratoplasty for Keratoconus: A Meta-Analysis.” Ed. Andrew W Taylor. PLoS ONE 10.1 (2015): e0113332. PMC. Web. 12 July 2015. .

DALK has less risk of suprachoroidal hemorrhage, cataract and glaucoma. DALK has less risk of endophthalmitis. DALK is anatomically stronger in case of trauma. DALK needs less steroid use.

Concerns about less visual outcome from interface haze has been decreased by the invention of big-bubble technique. 1.

Problems with big-bubble technique Big-bubble technique has a steep learning curve. You have to struggle until we get your first big bubble. And might have a tamper tantrum each time we fail. * Picture is downloaded from Google.com.

Achieving a big-bubble is not 100%. Even when you learned. Achieving a big bubble is not 100 %. * Picture is downloaded from Google.com

A 14% failure rate reported by Sarnicola. 3 A wide range of failure rates in achieving a big bubble has been reported. A 14% failure rate reported by Sarnicola. 3 Others have reported even higher failure rates. 4 3. Sarnicola V, Toro P. Blunt cannula for descemetic deep anterior lamellar keratoplasty. Cornea 2011;30:895-8. 4. Bhatt UK, Fares U, Rahman I, et al. Outcomes of deep anterior lamellar keratoplasty following successful and failed 'big bubble'. Br J Ophthalmol 2012;96:564-9

What happens if big-bubble is not achieved? Continue with conventional DALK to reach predescemet’s stroma (pd DALK). Convert to PKP. Since we saw the benefit of DALK over PKP thefore we don’t want to convert to PKP. At our place most patients doing corneal transplant are KCN. They are young patients. I have patient who did bilateral PKP elsewhere and went blind from all of a sudden rejection in both eyes. There are cases I have to do DALK at any cost. ( When other eye is PKP). 1.

Surgeons need alternative techniques to successfully complete DALK when the pneumatic injection fails to create a big bubble Having a reliable backup technique can increase the DALK success rate .

Most of the surgeons use a crescent blade to dissect the stroma to reach predescemet’s (pd DALK) To continue with pd DALK most surgeon use Crescent blade. Crescent blade is associated with high risk of performation It is difficult for some surgoen to get regular one plane dissection with crescent blade. Leaves irregular inferface. Traditionally, a crescent blade is used for this dissection, which can be difficult for surgeons to master and is associated with a high risk of perforation * Picture is downloaded from Google.com

Few use blunt dissection to reach the descemet’s or predescement’s Melles technique, cannot be utilized after failure to achieve a big bubble 5 Because Melles technique need good visualization of the spatula to complete the dissection and the emphysema from pneumatic injection after failed big-bubble is precluding visualization. 5. Melles GR, Lander F, Rietveld FJ, et al. A new surgical technique for deep stromal, anterior lamellar keratoplasty. Br J Ophthalmol 1999;83:327-33.

We conceptualize the use of blunt-tipped corneal mini-scissors to complete this dissection. * Picture is downloaded from Google.com

Blunt scissors lamellar dissection technique takes advantage of the emphysema and micro-detachment of descemet’s. Since the emphasyma faciltate blunt dissection and also microdetachments of the DM help the dissection. * Picture is downloaded from Google.com

Kim and et al, have reported the creation of micro-detachments at the level of Descemet’s membrane6 with pneumatic injection in the absence of a big bubble 6. Kim and etal “Histopathology and Spectral Domain OCT Findings of Pneumatic-assisted Dissection in DALK” Cornea. 2012 Nov;31(11):1288-93.

* Picture is from Kim and etal paper

* Picture is from Kim and etal paper

This technique leaves the strong Dua’s layer in place 7 This gives more strength to the structure of cornea. Less risk of perforation while dissecting. 7. Dua Hs and etal, “Human corneal anatomy redefined: a novel pre-Descemet's layer (Dua's layer)” Ophthalmology. 2013 Sep;120(9):1778-85.

Summery Anwar’s big-bubble is now the standard for DALK. Big-bubble achievement fails frequently. Alternative technique, that is comparable to big-bubble interface outcome, is needed in case big-bubble fails. Our “Scissors DALK” technique provides that alternative. 1.

Conclusion “Scissors DALK” appears to be reaching closet to the descemet’s compare to other non big-bubble technique. Study with more cases involved is needed to further prove the effectiveness of this technique Case-study has been published in Clinical Ophthalmology Journal 8 Larger study with up 20 cases is underway. 8. Anwar DS and etal, " Blunt scissos stormal dissection technique for deep anterior lamellar keratoplasty", Clin Ophthalmol. 2014 Sep 15;8:1849-54

Thank you

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