1. Deep anterior lamellar keratoplasty in children World Cornea Congress April 2010 Boston, MA Asim Ali, MD, FRCSC University of Toronto Hospital for Sick Children Toronto, Ontario, Canada Disclosure: The author has no financial interests related to the material of this poster.

2. Abstract Purpose To present a series of pediatric patients who underwent deep anterior lamellar keratoplasty (DALK) for stromal opacities or ectasia by one surgeon from 2007-2009. Methods A retrospective review of 12 consecutive patients with attempted DALK, age less than 18 years and follow-up of at least 4 months was performed. Indications for surgery, length of follow-up, complications and initial and final visual acuity were recorded. Results Successful DALK was performed in 12 eyes of 11 patients aged 1-17 years old. There was one macroperforation and conversion to penetrating keratoplasty. Non-healing epithelial defects occurred in 2 patients who developed microbial keratitis. Repeat DALKs were performed successfully. One patient developed reactivation of HSV in the graft and because of dense amblyopia a repeat graft was not attempted. Final visual acuity was unchanged or improved in all patients. Conclusions Deep anterior lamellar keratoplasty is a safe alternative to penetrating keratoplasty in children with corneal stromal opacities or ectasia.

3. Methods Records of 13 eyes of 12 consecutive patients with attempted DALK were reviewed Single surgeon from 2007-09 Surgical technique used ◦ Melles technique (1 case) ◦ Manual dissection (12 cases)  Trephination (Hessberg-Barron, 300-350 microns)  Sharp and semi-sharp dissection to pre-Descemet’s plane  Air injected to visualize stroma but big bubble not attempted

4. Results 12/13 eyes underwent successful manual DALK 1 eye was converted to PKP because of macroperforation 4 microperforations occurred but dissection was completed successfully 2 repeat DALKs (with tarsorraphy) were performed after persistent epithelial defects resulted in bacterial keratitis – both remain clear Vision remains unchanged or improved in all patients Grafts are clear in 11/12 eyes with mean follow- up of 11.8 months (range 6-22)

5. Table 1: Pre-operative characteristics Patie nt AgeEyeDiagnosisOtherPre-op BCVA 19 moREHerpes simplexCS UM* 29 yrREPhlectenulosis20/400 314 yrREKeratoconusAutism, eye-rubberFix + follow 14 yrLEKeratoconusFix + follow 415 yrREHurler syndrome20/200 51 yrLECorneal dermoidLinear nevus sebaceousCS UM* 68 yrLE? Herpes zoster20/100 72 yrLEBacterial keratitisNeurotrophic corneaLP 816 yrLEKeratoconusEye-rubber, OCD, TourettesCF 98 yrREDescemetocelePosterior blepharitis20/40 1014 yrLEBacterial keratitisSoft contact lens wearer20/70 115 yrREExposure keratopathyGoldenhar syndrome, lid coloboma repair 20/800 1213 yrLEKeratoconusCF * Central, steady + unmaintained

6. Table 2: Operative details PatientEyeResidual opacity Donor/recipi ent (mm) Intraoperative complications / comments 1RE--Macroperforation, converted to PKP 2RENo7.75 /7.5None 3RENo7.75 /7.5None LENo8.0 /7.5None 4REYes8.0 /7.5Microperforation 5LENo7.0 /6.5Previous crescentic graft, subsequent cataract extraction /IOL /pupilloplasty 6LEYes8.0 /7.5Microperforation 7LENo7.25 /7.0None 8LENo8.5 /8.0None 9REYes7.75 /7.5Microperforation 10LENo8.25 /8.0Microperforation 11RENo7.75 /7.5None 12LENo8.0 /7.5None

7. Table 3: Post-operative course Patie nt EyeComplicationsPost-op BCVA Follow -up Comments 1REGraft rejection20/200 2RENone20/4022 moAmbylopia 3RENone20/4012 mo LENone20/506 mo 4RENone20/806 moSutures in 5LENone20/20020 moDense amblyopia 6LESuture loosening at 6 weeks20/6011 moAmblyopia 7LE? HSV reactivation + scarHM13 moOpted not to regraft 8LENone20/408 mo 9REPersistent epi defect, bacterial ulcer, regraft 20/4022 moTarsorraphy 10LENone20/2012 mo 11REPersistent epi defect, bacterial ulcer, regraft 20/20014 moAmblyopia 12LENone20/506 mo

8. Figure 1: Slit lamp photo of patient 6 showing anterior stromal scar and thinning

9. Figure 2: Slit lamp photo of patient 12 showing Vogt striae and deep scarring

10. Discussion DALK was selected instead of PKP in our pediatric patients because of a lower risk of rejection and greater tectonic strength. Two of our patients (3 and 8) were forceful eye rubbers with psychiatric co-morbidities and the improved strength was reassuring. A manual technique instead of a big bubble technique was used to allow dissection of deep scars and minimize perforations, as we believe the benefit of reduced rejection outweighs the visual benefits in this patient group with other ocular co-morbidities especially amblyopia. The high rate of perforation may reflect the deep scarring in some corneas and also surgeon inexperience. Satisfactory visual outcomes were achieved even when residual corneal opacities remained in the recipient bed. Persistent epithelial defects lead to bacterial superinfection in two patients and we now perform temporary and permanent tarsorraphies following DALK surgery in susceptible patients.

11. Conclusions Manual DALK in children leads to improved visual outcomes, and in our view has significant advantages over PKP in this high risk group.