1. Deep anterior lamellar keratoplasty (DALK) in Tohoku University, Japan T Hariya MD, A Kubota MD PhD, M Uematsu MD, S Yokokura MD PhD,K Nishida MD PhD, Tohoku University of Medichine, Japan The authors have no financial interest in the subject matter of this poster.

2. PURPOSE Facilities where deep anterior lamellar keratoplasty (DALK) is done are few because of the difficulty of the technique and the high rate of descemet’s membrane rupture. To analyze visual acuity, endothelial cell dencity, graft survival and complications of 40 eyes undergone DALK in Tohoku University, Japan

3. METHOD STUDY DESIGN: Retrospective study from March, 2006 to August, 2009. All cases were operated by cornea specialists, and observed continuously after the operation for three months or more. Five cases were excluded because of dropout. NUMBER ： 39cases 40eyes OBSERVATION PERIOD: 8.1±9.9 (3-37)months MAN:FEMALE: 20:19 cases AGE: 57.0±19.3 years old SIMULTANEOUS SURGERY: PEA+IOL (5eyes), limbal transplantation (2eyes) ADDITIONAL SURGERY: PEA+IOL(3eyes), YAG laser(1eye)

4. PRIMARY DESEASES others ・ corneal opacity postoperative pterygium, 1 ・ macular dystorophy, 1 ・ corneal perforation after infection （ Candida ）, 1 ・ corneal perforation (rheumatism), 1 coneal opacity after infection ・ interstitial keratitis, 8 ・ herpes, 5 ・ trachoma, 2 ・ acantoamoeba, 1 ・ unknown, 1

5. TECHNIQUE OF DALK #1 mirror imaging technique #2 Visco-dissection technique #3 Big bubble technique #4 Small bubble technique #5 Double bubble technique #6 limbal approach #7 Hydrodelamination technique #8 Hooking technique We performed DALK with #7 until 2007., and with #8 from 2008. Hooking technique In Tohoku university

6. Case 62 years old MAN lattice corneal dystorophy type Ⅰ Preoperative visual acuity logMAR 1.5 ⇒ Postoperative visual acuity logMAR 0.3 1 year later

7. GRAFT SURVIVAL 35/40 eyes 88% In 5 eyes, corneal graft were failed because of following causes. ① corneal opacity after infection(unknown) →graft infection (Candida) ② corneal perforation due to rhematism →endothelial decompentation ③ trachoma →graft infection (Candida) ④ corneal opacity after interstitial keratitis →rejection ⑤ keratoconus →rejection

8. COMPLICATIONS ◆ Descemet rupture rate 12/51 eyes 24% ⇒ 11eyes converted to PKP(penetrating keratoplasty) ～ 2007 hydrodelamination technique 23% 2008 ～ hooking technique 17% Descemet rupture rate of operation with hooking technique is lower than that with hydrodelamination. 1) ◆ Elevation of intraocular pressure(IOP) 9/40 eyes 23% In all cases, elevation of IOP was temporary or normalized in eye-drop treatment. ◆ Double chamber 5/40 eyes 13% Injected SF6 gas into anterior chamber. (1 eye) 1) M.tsuchiyama et.al. tohoku university: Japanese society of ophthalmic surgeons

9. 1M 3M 6M 12M 24M improvement conservation reduction FIGURE1:logMAR Visual acuity improved by two or more. ※ counting finger=2.4 hand motion=2.7 light perception=3 RESULT 3 2 1 0 0 1 2 3 Preoperation visual acuity Final visual acuity FIGURE2: Preoperatin Visual acuity vs. final visual acuity in logMAR. It was improved in most cases.

10. RESULT ※ ※ ※ p<0.05 Pre-operation 1M3M12M6M n=20 n=12 n=13 n=22n=20 ↑ FIGURE3: The progression of endothelial cell density(ECD). The rate of ECD decrease was 24% at 6 month, 26% at 12month.

11. CONSIDERATION Descemet rupture rate24% Descemet rupture rate fell by selecting the technique. According to the other report, it was 39.2% 1),18.2 ％ 2),23% 3),23% 4),11.6% 5). There was no significant deference. Double chamber 13% It can get well naturally. And it is effective to inject SF6 gas into anterior chamber. Visual acuity It was improved in most cases. Endothelial cell dencity (ECD) It was decreasing. It was decreasing. There was no significant deference comparing to other reports. 1)Sugita et al:Br.J.Opthalmol.1997 、 2) Shimazaki et al:Am.J.Opthalmol.2002 3)Senoo et al:Br.J.Opthalmol.2005 、 4)Leccisotti et al:J Cataract Refract Surg.2002 5)Yu-Heng Yao:Cornea,September 2008

12. CONCLUSION DALK has a few complications, and can be considered effective treatment for corneal opacity without endothelial damage.