Anterior Lamellar Surgery

  • Naoyuki MaedaEmail author


Anterior lamellar keratoplasty (ALK) is classified into two categories: superficial anterior lamellar keratoplasty (SALK) and deep anterior lamellar keratoplasty (DALK).

Superficial anterior lamellar keratoplasty consists of an automated lamellar therapeutic keratoplasty (ALTK) as an optical procedure for the superficial stromal disorders and lamellar grafting as a therapeutic procedure for corneal perforation, corneal thinning, or ocular surface diseases.

Recently, DALK has been actively performed for the stromal pathologies of the cornea with healthy corneal endothelium as a selective lamellar keratoplasty for optical purposes. DALK is also performed as a therapeutic procedure for serious corneal infection that does not respond to pharmacological therapy.

The advantages of DALK over penetrating keratoplasty are the elimination of endothelial rejection and better ocular integrity. As a trade-off, a steep learning curve, intraoperative complications such as corneal perforation and postoperative complications including double chamber, persistent stromal folds, and insufficient visual recovery due to residual stromal opacity may be found. To solve these problems in DALK, novel procedures and new instruments are being developed.


Deep anterior lamellar keratoplasty Automated lamellar therapeutic keratoplasty Rejection reaction Selective lamellar keratoplasty Descemet’s membrane Femtosecond laser Big bubble technique 


  1. 1.
    Anshu A, Parthasarathy A, Mehta JS, Htoon HM, Tan DT. Outcomes of therapeutic deep lamellar keratoplasty and penetrating keratoplasty for advanced infectious keratitis: a comparative study. Ophthalmology. 2009;116:615–23.CrossRefPubMedGoogle Scholar
  2. 2.
    Anwar M, Teichmann KD. Deep lamellar keratoplasty: surgical techniques for anterior lamellar keratoplasty with and without baring of Descemet’s membrane. Cornea. 2002;21:374–83.CrossRefPubMedGoogle Scholar
  3. 3.
    Archila EA. Deep lamellar keratoplasty dissection of host tissue with intrastromal air injection. Cornea. 1984–1985;3:217–8.Google Scholar
  4. 4.
    Arenas E, Esquenazi S, Anwar M, Terry M. Lamellar corneal transplantation. Surv Ophthalmol. 2012;57:510–29.CrossRefPubMedGoogle Scholar
  5. 5.
    Asota I, Farid M, Garg S, Steinert RF. Femtosecond laser-enabled keratoplasty. Int Ophthalmol Clin. 2013;53:103–14.CrossRefPubMedGoogle Scholar
  6. 6.
    Bessant D, Dart J. Lamellar keratoplasty in the management of in-flammatory corneal ulceration and perforation. Eye. 1994;8:22–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Bhatt UK, Fares U, Rahman I, Said DG, Maharajan SV, Dua HS. Outcomes of deep anterior lamellar keratoplasty following successful and failed ‘big bubble’. Br J Ophthalmol. 2012;96:564–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Burkhart ZN, Feng MT, Price MO, Price FW. Handheld slit beam techniques to facilitate DMEK and DALK. Cornea. 2013;32:722–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Chen W, Qu J, Wang Q, Lu F, Barabino S. Automated lamellar keratoplasty for recurrent granular corneal dystrophy after phototherapeutic keratectomy. J Refract Surg. 2005;21:288–93.PubMedGoogle Scholar
  10. 10.
    Coster DJ, Lowe MT, Keane MC, Williams KA, Australian Corneal Graft Registry Contributors. A comparison of lamellar and penetrating keratoplasty outcomes: a registry study. Ophthalmology. 2014;121:979–87.CrossRefPubMedGoogle Scholar
  11. 11.
    De Benito-Llopis L, Mehta JS, Angunawela RI, Ang M, Tan DT. Intraoperative anterior segment optical coherence tomography: a novel assessment tool during deep anterior lamellar keratoplasty. Am J Ophthalmol. 2014;157:334–41.CrossRefPubMedGoogle Scholar
  12. 12.
    Dua HS, Faraj LA, Said DG, Gray T, Lowe J. Human corneal anatomy redefined: a novel pre-Descemet’s layer (Dua’s layer). Ophthalmology. 2013;120:1778–85.CrossRefPubMedGoogle Scholar
  13. 13.
    Fontana L, Parente G, Tassinari G. Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus. Am J Ophthalmol. 2007;143:117–24.CrossRefPubMedGoogle Scholar
  14. 14.
    Fontana L, Parente G, Di Pede B, Tassinari G. Candida albicans interface infection after deep anterior lamellar keratoplasty. Cornea. 2007;26:883–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Jafarinasab MR, Rahmati-Kamel M, Kanavi MR, Feizi S. Dissection plane in deep anterior lamellar keratoplasty using the big-bubble technique. Cornea. 2010;29:388–91.CrossRefPubMedGoogle Scholar
  16. 16.
    Jiménez-Alfaro I, Pérez-Santonja JJ, Gómez Tellería G, Bueno Palacín JL, Puy P. Therapeutic lamellar keratoplasty with an automated microkeratome. J Cataract Refract Surg. 2001;27:1161–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Jones MN, Armitage WJ, Ayliffe W, Larkin DF, Kaye SB, NHSBT Ocular Tissue Advisory Group and Contributing Ophthalmologists (OTAG Audit Study 5). Penetrating and deep anterior lamellar keratoplasty for keratoconus: a comparison of graft outcomes in the United Kingdom. Invest Ophthalmol Vis Sci. 2009;50:5625–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Kawashima M, Kawakita T, Shimmura S, Tsubota K, Shimazaki J. Characteristics of traumatic globe rupture after keratoplasty. Ophthalmology. 2009;116:2072–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Kenyon KR, Tseng SC. Limbal autograft transplantation for ocular surface disorders. Ophthalmology. 1989;96:709–22.CrossRefPubMedGoogle Scholar
  20. 20.
    Kinoshita S, Ohashi Y, Ohji M, Manabe R. Long-term results of keratoepithelioplasty in Mooren’s ulcer. Ophthalmology. 1991;98:438–45.CrossRefPubMedGoogle Scholar
  21. 21.
    Koh S, Maeda N, Nakagawa T, Higashiura R, Saika M, Mihashi T, Fujikado T, Nishida K. Characteristic higher-order aberrations of the anterior and posterior corneal surfaces in 3 corneal transplantation techniques. Am J Ophthalmol. 2012;153:284–90.CrossRefPubMedGoogle Scholar
  22. 22.
    Maeda N, Ueki R, Fuchihata M, Fujimoto H, Koh S, Nishida K. Corneal biomechanical properties in 3 corneal transplantation techniques with a dynamic Scheimpflug analyzer. Jpn J Ophthalmol. 2014;58:483–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Maurino V, Allan BD, Stevens JD, Tuft SJ. Fixed dilated pupil (Urrets-Zavalia syndrome) after air/gas injection after deep lamellar keratoplasty for keratoconus. Am J Ophthalmol. 2002;133:266–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Melles GR, Lander F, Rietveld FJ, Remeijer L, Beekhuis WH, Binder PS. A new surgical technique for deep stromal, anterior lamellar keratoplasty. Br J Ophthalmol. 1999;83:327–33.PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Melles GR, Remeijer L, Geerards AJ, Beekhuis WH. A quick surgical technique for deep, anterior lamellar keratoplasty using visco-dissection. Cornea. 2000;19:427–32.CrossRefPubMedGoogle Scholar
  26. 26.
    Muftuoglu O, Toro P, Hogan RN, Bowman RW, Cavanagh HD, McCulley JP, Mootha VV, Sarnicola V. Sarnicola air-visco bubble technique in deep anterior lamellar keratoplasty. Cornea. 2013;32:527–32.CrossRefPubMedGoogle Scholar
  27. 27.
    Nishida K, Yamato M, Hayashida Y, Watanabe K, Yamamoto K, Adachi E, Nagai S, Kikuchi A, Maeda N, Watanabe H, Okano T, Tano Y. Corneal reconstruction with tissue-engineered cell sheets composed of autologous oral mucosal epithelium. N Engl J Med. 2004;351:1187–96.CrossRefPubMedGoogle Scholar
  28. 28.
    Parthasarathy A, Por YM, Tan DT. Use of a “small-bubble technique” to increase the success of Anwar’s “big-bubble technique” for deep lamellar keratoplasty with complete baring of Descemet’s membrane. Br J Ophthalmol. 2007;91:1369–73.PubMedCentralCrossRefPubMedGoogle Scholar
  29. 29.
    Pellegrini G, Traverso CE, Franzi AT, Zingirian M, Cancedda R, De Luca M. Long-term restoration of damaged corneal surfaces with autologous cultivated corneal epithelium. Lancet. 1997;349:990–3.CrossRefPubMedGoogle Scholar
  30. 30.
    Pettit T. Corneoscleral free hand lamellar keratoplasty in Terrien’s marginal degeneration of the cornea: long-term results. Refract Corneal Surg. 1991;7:28–32.PubMedGoogle Scholar
  31. 31.
    Price Jr FW, Price MO, Grandin JC, Kwon R. Deep anterior lamellar keratoplasty with femtosecond-laser zigzag incisions. J Cataract Refract Surg. 2009;35:804–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmology. 2011;118:209–18.CrossRefPubMedGoogle Scholar
  33. 33.
    Sarnicola V, Toro P, Gentile D, Hannush SB. Descemetic DALK and predescemetic DALK: outcomes in 236 cases of keratoconus. Cornea. 2010;29:53–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Sarnicola V, Toro P, Sarnicola C, Sarnicola E, Ruggiero A. Long-term graft survival in deep anterior lamellar keratoplasty. Cornea. 2012;31:621–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Scott JA, Tan DT. Therapeutic lamellar keratoplasty for limbal dermoids. Ophthalmology. 2001;108:1858–67.CrossRefPubMedGoogle Scholar
  36. 36.
    Shehadeh-Mashor R, Chan CC, Bahar I, Lichtinger A, Yeung SN, Rootman DS. Comparison between femtosecond laser mushroom configuration and manual trephine straight-edge configuration deep anterior lamellar keratoplasty. Br J Ophthalmol. 2014;98:35–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Shimmura S, Tsubota K. Deep anterior lamellar keratoplasty. Curr Opin Ophthalmol. 2006;17:349–55.CrossRefPubMedGoogle Scholar
  38. 38.
    Shousha MA, Yoo SH, Kymionis GD, Ide T, Feuer W, Karp CL, O’Brien TP, Culbertson WW, Alfonso E. Long-term results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty. Ophthalmology. 2011;118:315–23.CrossRefPubMedGoogle Scholar
  39. 39.
    Singh M, Chew PT, Tan D. Corneal patch graft repair of exposed glaucoma drainage implants. Cornea. 2008;27:1171–3.CrossRefPubMedGoogle Scholar
  40. 40.
    Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol. 1997;81:184–8.PubMedCentralCrossRefPubMedGoogle Scholar
  41. 41.
    Susiyanti M, Mehta JS, Tan DT. Bilateral deep anterior lamellar keratoplasty for the management of bilateral post-LASIK mycobacterial keratitis. J Cat Ref Surg. 2007;33:1641–3.CrossRefGoogle Scholar
  42. 42.
    Tan DT, Ang LP. Automated lamellar therapeutic keratoplasty for post-PRK corneal scarring and thinning. Am J Ophthalmol. 2004;138:1067–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Tan DT, Anshu A, Parthasarathy A, Htoon HM. Visual acuity outcomes after deep anterior lamellar keratoplasty: a case-control study. Br J Ophthalmol. 2010;94:1295–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Tan DT, Dart JK, Holland EJ, Kinoshita S. Corneal transplantation. Lancet. 2012;379:1749–61.CrossRefPubMedGoogle Scholar
  45. 45.
    Terry MA. The evolution of lamellar grafting techniques over twenty-five years. Cornea. 2000;19:611–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Thoft RA. Keratoepithelioplasty. Am J Ophthalmol. 1984;97:1–6.CrossRefPubMedGoogle Scholar
  47. 47.
    Tsubota K, Satake Y, Kaido M, Shinozaki N, Shimmura S, Bissen-Miyajima H, Shimazaki J. Treatment of severe ocular-surface disorders with corneal epithelial stem-cell transplantation. N Engl J Med. 1999;340:1697–703.CrossRefPubMedGoogle Scholar
  48. 48.
    Vajpayee RB, Vasudendra N, Titiyal JS, Tandon R, Sharma N, Sinha R. Automated lamellar therapeutic keratoplasty (ALTK) in the treatment of anterior to mid-stromal corneal pathologies. Acta Ophthalmol Scand. 2006;84:771–3.CrossRefPubMedGoogle Scholar
  49. 49.
    Visby E, Hjortdal J, Nielsen K. Evaluation of grafted patients with donor corneas that today are more than 100 years old. Acta Ophthalmol. 2014;92:478–81.CrossRefPubMedGoogle Scholar
  50. 50.
    Yao YF. A novel technique for performing full-bed deep lamellar keratoplasty. Cornea. 2008;27 Suppl 1:S19–24.CrossRefPubMedGoogle Scholar
  51. 51.
    Yoo SH, Kymionis GD, Koreishi A, Ide T, Goldman D, Karp CL, O’Brien TP, Culbertson WW, Alfonso EC. Femtosecond laser-assisted sutureless anterior lamellar keratoplasty. Ophthalmology. 2008;115:1303–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of OphthalmologyOsaka University Graduate School of MedicineSuitaJapan

Personalised recommendations