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Clinical outcome of DALK in Keratoconus – A one year follow up

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Clinical outcome of DALK in Keratoconus – A one year follow up. Authors: Somasheila I Murthy, MD, Smruthi rekha Priyadarshini , MD, Jagadesh Reddy, MD and Prashant Garg , MD. Affiliation: Cornea and anterior segment service,

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Clinical outcome of DALK in Keratoconus – A one year follow up

Authors: Somasheila I Murthy, MD, SmruthirekhaPriyadarshini, MD, Jagadesh Reddy, MD

and PrashantGarg, MD.

Affiliation: Cornea and anterior segment service,

L. V. Prasad Eye Institute, KallamAnji Reddy Campus, Hyderabad, India

The authors have no financial interest in the subject matter of this poster



  • Inclusion criteria: all cases of keratoconus that underwent DALK with a minimum follow-up of one year
  • Pre-operative evaluation included:
    • Visual acuity
    • Slit lamp examination
    • Central corneal thickness
    • Corneal topography
  • Study purpose: To evaluate the visual outcome and complications of deep anterior lamellar keratoplasty (DALK) in keratoconus
  • Study design: retrospective interventional case series
  • Study location: Cornea and anterior segment service, LV Prasad eye Institute, Hyderabad, India


  • The data obtained included: pre and post-operative:
  • Best corrected Snellen’s visual acuity
  • Slit-lamp examination for assessment of graft clarity
  • Central corneal thickness
  • Corneal topography using Orbscan
  • Anterior segment optical coherence tomography post-operatively in some cases
  • Surgical technique:
  • 2 techniques:
    • Big-bubble technique
    • Manual dissection in layers
    • Combination
  • Primary outcome measures:
    • Visual acuity
    • Graft clarity
  • Secondary outcome measures:
    • Nonprogression of keratoconus
    • Graft failure due to edema or rejection
    • Complications rate


Table 1: Age distribution

  • During 2004 to 2008, 49 eyes of 48 patients underwent DALK
  • Twenty-two eyes completed one year follow-up
  • Mean age: 18.63 (range 11 to 43 years) with 77% under 20 years
  • Fifteen were male and seven female patients

Results: pre and post-operative visual acuity

Table 3: Post-operative visual acuity

Table 2: Pre-operative visual acuity



Table 4: Surgical technique

  • Corneal thickness ranged from 427 to 591 microns
  • Donor graft size ranged from 7.5 to 10.5

Results: graft clarity and complications

Table 5: Graft clarity

Table 6: Complications



  • Best-corrected visual acuity at one year was 20/40 or better in 16/22 cases (73%)
  • 16/22 cases had clear graft, with 5/22 showing interface haze or scarring
  • No major complications like glaucoma, graft failure or progression were noted
  • Minor suture related complications (loose or broken sutures) were noted in 9 eyes (40%)


  • Penetrating keratoplasty is the accepted surgical treatment for keratoconus and has an excellent five-year graft survival rate1,2
  • However, it can fail due to allograft rejection and endothelial cell loss
  • Deep anterior lamellar keratoplasty replaces anterior diseased part of the cornea while retaining the host endothelium and has the advantage of reducing the risks of graft rejection and intraocular complications


  • Various authors have reported their results of DALK and have shown comparable visual acuities with PK with fewer post-operative complications3, 4, 5 Our study also shows similar results
  • Therefore, despite this technique being more demanding surgically, it is worthwhile to perform DALK for keratoconus and PK should be done only as a last resort


  • Visual acuity outcomes of DALK in keratoconus are good in majority of cases
  • In comparison to penetrating keratoplasty, there are fewer post-operative complications and majority encountered were minor
  • DALK is perhaps the preferred choice for the surgical management of keratoconus


Pramnik S, Musch DC, Sutphin JE, Farjo AA. Extended long-term outcomes of penetrating keratoplasty for keratoconus. Ophthalmology 2006;113:1633-1638

Zadok D, Schwarts S, Marcovich A, et al. Penetrating keratoplasty for keratoconus: long term results. Cornea 2005;24:959-961

Watson SL, Ramsay A, Dart JKG, et al. Comparison of deep lamellar keratoplasty with penetrating keratoplasty in patients with keratoconus. Ophthalmology, 2004;111:1676-1682

Sarnicola V, Toro P, Gentile D, et al. Descemetic DALK and pre-descemetic DALK: outcomes in 236 cases of keratoconus. Cornea 2010 Jan;29(1):53-9

Han DY, Mehta JS, Por YM et al. Comparison of outcomes of lamellar keratoplasty and penetrating keratoplasty in keratoconus. Am J Ophthalmol 2009;148(5):629-31