Clinical science

Penetrating keratoplasty versus deep anterior lamellar

keratoplasty: comparison of optical and visual
quality outcomes
nal,2 David Pinero Llorens,3,4
Esin Sogutlu Sar,1 Anil Kubaloglu,1 Mustafa U
zerturk1
Arif Koytak,5 Ali Nihat Ofluoglu,6 Yusuf O
1

Kartal Training and Research

Hospital, Istanbul, Turkey
2
Department of Ophthalmology,
Akdeniz University Medical
Faculty, Antalya, Turkey
3
ptica,
Departamento de O
Farmacologa y Anatoma,
Universidad de Alicante,
Alicante, Spain
4
Foundation for the Visual
Quality (FUNCAVIS, Fundacion
para la Calidad Visual), Alicante,
Spain
5
Bezmi Alem University,
Medical Faculty, Ophthalmology
Department, Istanbul, Turkey
6
Alman Hastanesi,
Ophthalmology Department,
Istanbul, Turkey
Correspondence to
nal, Akdeniz
Dr Mustafa U
University, Medical Faculty
Department of Ophthalmology,
Antalya 07070, Turkey;
mustafaunalmd@gmail.com
Accepted 26 May 2012
Published Online First
20 June 2012

ABSTRACT
Purpose To evaluate and compare visual and optical
performance outcomes by means of analysis of the
contrast sensitivity function (CSF) and ocular higher order
aberrations (HOA) in patients with keratoconus who had
deep anterior lamellar keratoplasty (DALK) or penetrating
keratoplasty (PK).
Methods In this prospective, randomised case series,
174 eyes of 140 consecutive patients with moderate to
advanced keratoconus were included. The big-bubble
technique was attempted to perform DALK.
Intraoperative and postoperative complications,
uncorrected visual acuity, best spectacle-corrected
visual acuity (BSCVA), refraction, topographic
astigmatism, CSF and ocular HOA were evaluated.
Results The DALK and PK groups consisted of 99 and
75 eyes, respectively. Postoperative BSCVA was 20/40
or better in 64 eyes (85%) in the PK group and and 82
eyes (83%) in the DALK group (p>0.05). The mean
spherical equivalent and maximum keratometry were

1.50 (
6.25 to +4.75) and 46.85 (40.60 to 56.00) in
the PK group and
2.25 (
8.75 to +4.00) and 46.90
(40.60 to 53.60) in the DALK group, respectively. The
differences were not statistically significant (p0.08 and
p0.66, respectively). No significant differences in
photopic contrast sensitivity were found for each of the
spatial frequencies (p>0.05 for all). However, mesopic
contrast sensitivity for three cycles/degree was
significantly higher in the DALK group (p0.01). No
significant differences between groups were detected
for any of the aberrometric parameters (p>0.05).
Conclusions DALK is an alternative treatment option in
eyes with moderate to advanced keratoconus, providing
comparable results to PK in terms of visual acuity,
refraction, CSF and HOA.

INTRODUCTION
Penetrating keratoplasty (PK) has been considered
the gold standard for the treatment of advanced
keratoconus for many years because it is an effective and safe technique for providing good visual
and optical outcomes. However, to replace the full
thickness of the cornea has been associated with
a higher risk of endothelial graft rejection compared
with lamellar keratoplasty.1 2
Deep anterior lamellar keratoplasty (DALK)
involves removal of the diseased anterior layers of
the corneal stroma and preserves the healthy
Descemet membrane (DM) and endothelium of the
host. The main advantage of DALK is that the
patients own endothelium is retained, which
Br J Ophthalmol 2012;96:1063e1067. doi:10.1136/bjophthalmol-2011-301349

eliminates the risk of endothelial graft rejection,

and preserves endothelial cell density.3e10
In spite of the potential advantages of anterior
lamellar surgery over PK, there have been some
concerns regarding the visual function achieved by
patients with lamellar graft. This has been attributed mainly to hostedonor interface opacities or
irregularity.11 12 However, DALK has gained popularity again because of improvements in surgical
techniques and the availability of new surgical
instruments and devices that have helped to
improve surgical success and reduce surgery
time.3e10
Because of increasing numbers of DALK surgeries
in recent years, comparison of visual and optical
outcomes after DALK and PK has been a research
subject of interest. Although some studies have
reported visual outcomes to be comparable,13e17
several others have documented less favourable
results after DALK surgery.11 12 18e20 We aimed to
extend the current information on the visual and
optical performance outcomes in keratoconus
patients undergoing DALK or PK. To our knowledge
the current study is the largest case series in the
literature comparing the two different techniques
in terms of optical and visual outcomes.

METHODS
This study was a prospective, randomised, interventional case series. Clinical data belonging to all
patients who underwent DALK or PK for the
management of keratoconus at Kartal Training and
Research Hospital between 1 September 2006 and 1
January 2009 were analysed. Data were recorded
prospectively and reviewed retrospectively.
All patients were informed about the advantages
and disadvantages of the procedure. An informed
consent was obtained from all patients in accordance with the Declaration of Helsinki. Approval
was obtained from the Institutional Review Board
of Kartal Training and Research Hospital. Patients
who were lost to follow-up were excluded from the
data analysis. Only the eyes that had all the sutures
out were included.
Keratoconus diagnosis was based on corneal
topography and slit lamp ndings such as asymmetric bowtie pattern, stromal thinning, conical
protrusion of the cornea at the apex, Vogt striae, or
anterior stromal scar. Inclusion criteria for the
study were eyes with moderate or advanced keratoconus, leading to dissatisfaction with spectacle or
contact lens corrected vision, with contact lens
wearing, or unsuccessful contact lens t. Patients
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Clinical science
were recruited regardless of minimum pachymetry or the cone
steepness, shape, or base size. Patients with other concomitant
diseases that could affect vision, with a history of previous
intraocular surgery were not included in the study.

Surgical technique
All eyes were operated on by a single experienced anterior
segment surgeon (AK). DALK was performed by using the bigbubble technique described by Anwar and Teichman.21 This
group was termed descemetic DALK (dDALK). When a big
bubble could not be generated after repeated attempts, a layerby-layer manual dissection was performed. This group was
termed predescemetic DALK (pdDALK).
Full-thickness cornea-scleral donor buttons stored in Optisol
GS were used for transplantation. The donor cornea was
punched with Barron trephine punch blades with diameters
ranging from 7.25 to 9.00 mm. The endothelium of donor
buttons was peeled after staining with trypan blue dye. The
button was secured in place using 10/0 nylon sutures.
PK procedures were performed using the standard technique.
The donor cornea was punched with diameters ranging from 7.25
to 9.00 mm. The suturing technique consisted of 16-bite interrupted or one single running with 16e18 bites or a combination
of both, according to the surgeons preference in both groups.
Interrupted sutures were chosen if there was a peripheral corneal
vascularisation or a history of vernal keratoconjunctivitis.
After all keratoplasty procedures, topical ciprooxacin 0.3%,
prednisolone acetate 1% and preservative-free articial tear eye
drops six times per day for 1 month was prescribed. Articial
tears and the prednisolone acetate 1% eye drop dose were
tapered off over the rst 3e6 months of the postoperative period
in DALK patients and 6e9 months in PK patients.
Preoperatively and postoperatively, a complete ophthalmological examination was performed in both groups, including
logMAR uncorrected visual acuity (UCVA), logMAR best
spectacle-corrected visual acuity (BSCVA), manifest refraction,
slit lamp biomicroscopy and corneal topographic analysis with
the Orbscan II system (Bausch & Lomb, Rochester, New York, USA).

Contrast sensitivity measurement

The CSV-1OOOE contrast sensitivity chart (VectorVision,
Greenville, Ohio, USA) was used. This test consists of four4
rows of sine-wave gratings (three, six, 12, 18 cycles/degree) that
had to be observed by the patient with full correction in place at
a distance of 2.5 m. After an initial demonstration, the contrast
threshold was measured for each spatial frequency. All patients
were tested under both mesopic and photopic conditions and
the results were expressed in log units of contrast sensitivity.

Wavefront aberration measurement

After measuring the contrast sensitivity function (CSF), cyclopentolate 1% eyedrops were instilled and when the pupil
diameter was larger than 5 mm, ocular wavefront measurement
was performed using the Zywave II aberrometer with the
Zywave software version 5.2 (Bausch & Lomb). This aberrometer was used to calculate the higher order aberration (HOA)
in terms of Zernike polynomials up to the fth order. Three
measurements were taken from each eye, and the average was
used for statistical analysis. All Zernike coefcients were transformed to the standard form as recommended by the Optical
Society of America.22

Statistical analysis
Data were recorded as the mean6SD (range). SPSS statistics
software package V.15.0 for Windows was used for statistical
1064

analysis. Normality of all data samples was checked rst by

means of the KolmogoroveSmirrnov test. When parametric
analysis was possible, the Students t test for unpaired data was
used for comparisons, whereas when parametric analysis was
not possible, the ManneWhitney test was applied. A p value of
less than 0.05 was considered statistically signicant.

RESULTS
Operative and postoperative data
A total of 174 eyes of 140 consecutive patients was included.
One hundred and four eyes underwent DALK surgery. Conversion to PK was needed in ve eyes because of the macroperforation. Therefore, the PK group consisted of 75 eyes of 55
patients and the DALK group consisted of 99 eyes of 80 patients.
Complete DM exposure could be achieved in 88 (88.9%) cases
via the big-bubble in the dDALK group and a layer-by-layer
manual stromal dissection was needed in 11 eyes (11.1%) in the
pdDALK group.
Table 1 summarises the preoperative data of the eyes. No
statistically signicant differences between groups were found
with regard to age, UCVA, BSCVA, corneal astigmatism and
maximal keratometric readings (p>0.05 for all).
No intraoperative complication occurred in the PK group.
Microperforation occurred in eight eyes (8.0%) in the DALK
group. Interface haze was not seen in any eyes. Double anterior
chamber was seen in one eye (1.0%) and resolved after intracamaral air injection. Graft rejection episodes were seen in seven
eyes (9.3%) in the PK group; but no grafts were lost as a result of
graft rejection. Stromal graft rejection episodes were seen in one
eye (1.0%) in the DALK group, which was completely resolved
with topical corticosteroids.

Refractive and visual outcome

The mean period of time between surgery and complete suture
removal was of 16.6065.80 months (range 12e28 months) and
12.7863.02 months (range 8e20 months) in the PK and DALK
groups, respectively (p0.04). So suture removal and the visual
examination giving the denitive outcomes could be performed
earlier in the DALK group. The mean period of time between
surgery and the last complete postoperative examination was
25.5366.18 months (range 18e36 months) and 21.5464.25
months (range 15e26 months) in the PK and DALK groups,
respectively (p0.09).
Postoperative BSCVA was 20/40 or better in 64 eyes (85%) in
the PK group and in 82 eyes (83%) in the DALK group (p>0.05).
Table 2 summarises the postoperative visual outcome and
Table 1

Preoperative data of the study eyes

Mean (SD)
median (range)
No of eyes
Age (years)
LogMAR UCVA
LogMAR BSCVA
Kmax (D)
AST (D)

PK group

DALK group

75
28.44 (7.82)
28 (15 to 51)
1.63 (0.30)
1.70 (1.00 to 2.00)
1.41 (0.34)
1.70 (0.69 to 1.70)
60.25 (2.44)
59 (57 to 65)
7.50 (2.68)
7.00 (3.90 to 14.00)

99
27.59 (4.97)
27 (16 to 44)
1.51 (0.27)
1.70 (1.00 to 2.00)
1.27 (0.30)
1.30 (0.69 to 1.70)
59.33 (2.08)
59 (56 to 65)
7.20 (2.23)
6.90 (3.90 to 14.00)

p Value
0.49
0.07
0.05
0.12
0.93

AST, central corneal astigmatism; BSCVA, best spectacle-corrected visual acuity; D,

dioptres; DALK, deep anterior lamellar keratoplasty; Kmax, maximum central keratometric
reading; PK, penetrating keratoplasty; UCVA, uncorrected visual acuity.

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Clinical science
Table 2 Postoperative visual, refractive and keratometric conditions of
the study eyes
Mean (SD)
median (range)
LogMAR UCVA
LogMAR BSCVA
Sphere (D)
Cylinder (D)
SE (D)
Kmax (D)

PK group

DALK group

p Value

0.49 (0.36)
0.39 (0.04 to 1.30)
0.14 (0.17)
0.09 (0.00 to 0.52)
+0.38 (3.21)
+0.63 (
6.75 to +8.25)

3.67 (1.69)

3.50 (
7.50 to
1.25)

1.67 (2.99)

1.50 (
6.25 to +4.75)
47.36 (3.28)
46.85 (40.60 to 56.00)

0.60 (0.39)
0.52 (0.00 to 1.60)
0.18 (0.15)
0.15 (0.00 to 0.52)

0.88 (2.75)

1.25 (
6.00 to +4.00)

3.16 (2.04)

3.25 (
7.50 to 0.00)

2.27(3.31)

2.25 (
8.75 to +4.00)
47.16 (2.77)
46.90 (40.60 to 53.60)

0.23

degree and 0.48 for 18 cycles/degree). Comparing the subgroups,

the mean CSF under photopic and mesopic conditions were not
different between the dDALK and pdDALK groups for each of
the spatial frequencies (p>0.05).

Wavefront aberration outcome

0.09
0.07
0.98
0.08
0.66

BSCVA, best spectacle-corrected visual acuity; D, dioptres; DALK, deep anterior lamellar
keratoplasty; Kmax, maximum central keratometric reading; PK, penetrating keratoplasty;
UCVA, uncorrected visual acuity.

Wavefront aberrometric analyses were obtained in 28 eyes in the

PK group (37%) and 50 eyes (50%) in the DALK group. Figure 2
shows mean and standard deviations of the ocular aberrometric
parameters obtained with the Zywave system. Parameters
analysed included total root mean square (RMS), higher order
RMS (HOA RMS), and RMS of HOA without considering the
Zernike term corresponding to the primary spherical aberration
(HOA RMS without Z(4,0)). No signicant differences between
groups were detected (p values were 0.88 for total RMS, 0.80 for
HOA RMS; 0.39 for HOA RMS without Z(4,0). We could not
make a comparison between the dDALK and pdDALK groups
because no pdDALK patient had wavefront aberrometric analysis.

DISCUSSION
refractive status of the study eyes. No signicant differences
between the DALK and PK groups in any postoperative visual
and refractive parameter were found (p>0.05). Comparing the
subgroups, postoperative visual and refractive parameters were
not signicantly different between the dDALK and pdDALK
groups (p>0.05).

Contrast sensitivity outcome

Figure 1 shows the mean CSF under photopic and mesopic
conditions for the two groups of eyes. No signicant differences
in photopic contrast sensitivity were found for each of the
spatial frequencies between the DALK and PK groups (p values
0.28 for three cycles/degree, 0.43 for six cycles/degree, 0.46 for 12
cycles/degree and 0.48 for 18 cycles/degree). However, mesopic
contrast sensitivity for three cycles/degree was signicantly
higher in the DALK group (p0.01). For the remaining spatial
frequencies in mesopic condition, no signicant differences were
detected (p values; 0.09 for six cycles/degree, 0.37 for 12 cycles/

DALK has gained popularity as a treatment option for eyes with

healthy endothelium because it has several advantages over PK.
In the current interventional case series study, we assessed and
compared the postoperative visual, refractive and optical
performance outcomes in keratoconic eyes undergoing DALK or
PK. We found that DALK may be a good alternative treatment
option in eyes with moderate to advanced keratoconus,
providing comparable results to PK in terms of visual acuity,
refraction, CSF and HOA.
Over the past few years, a number of reports have shown
comparable visual outcomes after DALK and PK.13e17 Percentages of patients having a BSCVA of 20/40 or greater have been
reported ranging between 73% and 91% after PK in keratoconus
patients. Similar results were also reported after DALK surgery
in keratoconus patients, ranging between 72% and 92%.3
However, several others have shown limited visual results
after lamellar surgery.11 12 18e20 One of the main problems
with DALK surgery has been reported to be the inability to

Figure 1 Mean contrast sensitivity

function under photopic and mesopic
conditions for two groups analysed in
the study: PK, penetrating keratoplasty
group (black line), and DALK,
deep anterior lamellar keratoplasty
(grey line).

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1065

Clinical science
Figure 2 Mean values and standard
deviations of the ocular aberrometric
parameters measured with the Zywave
system in the two groups analysed in
the study. PK, penetrating keratoplasty
(grey bars); DALK, deep anterior
lamellar keratoplasty (white bars); total
RMS, total root mean square; HOA
RMS, higher order aberration RMS;
HOA w/o Z(4,0) RMS, RMS of HOA
without considering the Zernike term
corresponding to the primary spherical
aberration.

obtain a smooth interface between donor tissue and recipient

DM.11 12 23 This led to stromal scarring and interface opacities,
especially when layers of host stroma remained on the recipient
DM. With the introduction of advanced techniques, such as the
big-bubble technique of Anwar and Teichmann21 to separate the
stroma from DM, clearer interfaces in lamellar keratoplasty were
achieved. These technical improvements in deep lamellar
dissections are thought to promote better postoperative visual
results, which are comparable to those achieved with PK.13e17 24
In the current series, we also found no statistically signicant
differences in terms of UCVA and BSCVA between the PK and
DALK groups.
Complete baring of DM provides a smooth interface. This is
very important to get comparable outcomes after DALK surgery
with PK. Interface haze may interfere with BSCVA and CSF and
increase HOA. The bared DM was successfully exposed with the
big-bubble technique in 89% of the eyes of the current series,
which is in line with other published series that reported rates of
successful big-bubble technique between 56% and 82.4% in
keratoconus patients.3
The goal of kerotoplasty is to improve uncorrected vision in
keratoconic eyes without the aid of spectacles and/or contact
lenses. As a general agreement, high-contrast distance visual
acuity and residual refractive error are correlated with overall
patient visual function and satisfaction following refractive
surgery.25 However, many patients with minimal residual
spherocylindrical error and excellent uncorrected distance visual
acuity following refractive surgery are dissatised with their
postoperative quality of vision. So visual acuity measurements
may not always be a reliable indicator of good visual performance. The evaluation of contrast sensitivity that measures the
minimally perceptible resolution at various levels of contrast and
spatial frequency may be a more sensitive indicator of optical
performance after corneal grafting surgery, which is a procedure
that has been found to increase HOA signicantly.17 In the
current study, no signicant differences in photopic contrast
sensitivity for any spatial frequency were found between the
PK and DALK groups. This nding was consistent with
those obtained in other studies comparing CSF after PK and
DALK.14 15 17 20 However, we observed a slight trend towards
1066

better outcomes in mesopic contrast sensivity with DALK. This

contrasts with the ndings of Ardjomand et al,20 who compared
the postoperative visual functions after DALK (with the Melles
technique) and PK and correlated them with corneal thickness.
They found a trend towards a reduction of contrast vision in the
DALK group with residual stromal tissue exceeding 80 mm. In
the current study, we used the big-bubble technique of Anwar
and Teichmann,21 which is assumed to have the advantage of
exposing a smooth surface between host and donor cornea and
then not causing a deterioration of the ocular optical quality as
a consequence of aberrations and scattering.
However, we found that mesopic contrast sensitivity for three
cycles/degree was signicantly higher in the DALK group. So the
only difference in contrast sensitivity between the DALK and PK
groups tends to occur as the illumination level diminishes and
consequently the pupil size increases. This may be largely due to
a smooth interface in the periphery of DALK patients. Also, the
patients own DM provides an excellent optical quality even in
the large pupil sizes in mesopic conditions.
The airecornea interface is the rst and most important
refractive medium and constitutes most of the total refractive
power of the eye. Also, in normal or eyes with grafted corneas,
the anterior corneal surface is the most important source of
optical aberrations, which are irregularities or imperfections in
the optical system of the eye that cannot be corrected by simple
spherical or astigmatic corrections. As in the case of CSF, HOA
can also interfere with perfect visual performance. Postoperative
halos, glare and decreased contrast sensitivity in patients with
good visual acuity have been suggested to be related to HOA.17
The analysis of these optical errors is thus mandatory to
perform a more complete evaluation of the ocular optical quality
in patients with keratoplasty.
By using corneal or ocular wavefront measurements, previous
studies found that patients who underwent PK had signicantly
greater HOA than those of controls.26 These have been linked to
the different donor curvature, thickness and diameter compared
with those of the recipient, as well as compression of sutures
and wound healing. Whether DALK causes more or less HOA
than PK was not clearly investigated in large series. In the
current study, we found no signicant differences between the
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Clinical science
PK and DALK groups for any of the three aberrometric parameters evaluated (total RMS, HOA RMS, and HOA RMS without
Z(4,0)). This may indicate that the graft interface in DALK does
not induce more total HOA or the undisturbed posterior host
corneal surface may compensate any new HOA associated with
DALK. Although Javadi et al17 found a signicantly higher
magnitude of spherical aberration in DALK based on the ndings
on a relatively small sample, our results are in concordance with
those of Ardjomand and colleagues,20 revealing the presence of
no signicant differences between DALK and PK in terms of
HOA RMS. A success rate of 89% with the big-bubble technique
might also explain why our outcomes are not statistically
signicant. It should also be noted that in the current study we
used a HartmanneShack aberrometer that has been proved to be
of limited value when evaluating eyes with large amounts of
HOA, especially due to the spot crowding phenomenon.27
Furthermore, we used an aberrometer with a more limited
sampling than others that are commercially available.28
In conclusion, DALK with the big-bubble technique is an
alternative treatment option in eyes with moderate to advanced
keratoconus, providing comparable results to PK.
Funding MU was supported by Akdeniz University Scientific Research Projects Unit.
Other authors indicate no government or non-governmental financial support.

7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Competing interests None.

Patient consent Obtained.

21.

Ethics approval Approval was obtained from the Institutional Review Board of Kartal
Training and Research Hospital.

22.

Provenance and peer review Not commissioned; externally peer reviewed.

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