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Deep Lamellar Endothelial Keratoplasty (DLEK)

Method of endothelial transplant with the use of a femtosecond laser.


Deep Lamellar Endothelial Keratoplasty (DLEK) is an endothelial cell transplant technique developed to allow transplant of the corneal endothelial cell layer and its basement membrane, also known as the Descement's layer.

Alternative to Transplant

DLEK is an alternative to PKP, which requires the full thickness of the cornea to be replaced. PKPs are no fun, having a long vision recovery period, and are not terribly predictable.

Corneal Distress

Endothelial distress is a leading cause of the need for a corneal transplant. The primary problem is endothelial cell dystrophy (Fuch's Dystrophy), or endothelial cell loss from P-IOL, during cataract surgery or RLE, trauma to the eye, and other disease.

When the endothelial cells become compromised, a transplant can often resolve the problem. Unfortunately, transplanting just the endothelial layer and Decement's on the underside of the cornea inside the eye is not exactly easy.

Transplant Just Endothelium

DLEK is an endothelial cell transplant technique wherein a disk of endothelial cell tissue is removed from a donor cornea and placed on the underside of the recipient cornea, replacing a disk of endothelial cell tissue of equal size that has been removed from the recipient. Development of DLEK using mechanical scalpels and customized cutting tools works, but tends to create a very uneven transplant with poor adhesion. The disk can be created with a mechanical device, or with the femtosecond laser microkeratome.

Femtosecond Laser

The femtosecond laser was developed for creation of Bladeless Lasik flaps, but is finding uses in many other areas. The femtosecond makes DLEK much more predictable with a faster vision recovery time.

From the front side of the cornea, the laser creates a lamellar incision deep in the recipient's cornea just anterior to Descement's. When this circular incision is complete, the laser then cuts the sides by making incision from the level of the lamellar incision back through the bottom of the cornea. This creates a disk of just Decement's and endothelium in a very precise form - within about 10 microns of desired size.

The laser then creates an identical disk from donor tissue using the same process. The recipient's disk is rolled up and removed through a relatively small (by PKP standards, anyway) 5.0mm incision at the edge of the cornea, and the donor disk is rolled up, placed inside the eye through the same incision created to remove the bad endothelium layer, and then is unfolded and fitted into the "hole" created by the removal of the recipient's disk.

The cornea's natural "suction" holds the disk in place without sutures or biological glues.

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Recent DLEK Medical Journal Articles...

Related Articles

Secondary "thin-DSEK" after long-term graft failure in DLEK: a double transplanted cornea.

Cornea. 2011 Jul;30(7):828-31

Authors: Dirisamer M, Acis G, Dapena I, Ham L, Versteeg FF, Melles GR

Abstract
PURPOSE: To describe a case of secondary "thin Descemet stripping endothelial keratoplasty" ("Thin-DSEK"), for borderline decompensation 6 years after an initial deep lamellar endothelial keratoplasty (DLEK).
METHODS: In a 31-year-old man, who initially underwent a DLEK for bullous keratopathy in the presence of a phakic intraocular lens, a secondary Thin-DSEK was performed, while leaving the entire DLEK graft (including the donor Descemet membrane and the endothelium) in situ.
RESULTS: After the initial DLEK, the best-corrected visual acuity (BCVA) improved from 20/200 (0.1) to 20/25 (0.8). Six years later, the transplanted cornea showed intermittent decompensation with a decrease in BCVA again to 20/200 (0.1). After the secondary Thin-DSEK, the BCVA improved again to 20/25 (0.8) at 1 month postoperatively and remained stable thereafter.
CONCLUSIONS: Our case may show that a secondary DSEK may be a simple and effective treatment to manage secondary graft failure after DLEK. Despite the presence of a "double" stromal interface in the visual axis, secondary Thin-DSEK may provide visual rehabilitation similar to that after primary Thin-DSEK.

PMID: 21317783 [PubMed - indexed for MEDLINE]

 


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