I. Review of Corneal Anatomy
II. Anterior Segment Disorders Requiring Corneal Transplant
A. Anterior Cornea
1. Keratoconus
2. Herpes simplex
3. Corneal stromal dystrophies
4. Stem cell failure
5. Corneal scars
B. Posterior Cornea
1. Aphakic bullous keratopathy
2. Pseudophakic bullous keratopathy
3. Graft failure
4. Fuch’s dystrophy
5. Other endothelial dystrophies
III. Penetrating Keratoplasty (PKP)
A. Technique
B. Advantages
c. Disadvantage
D. Clinical results
IV. Anterior Keratoplasty
A. Lamellar Keratoplasty
1. Technique
2. Advantages
3. Disadvantage
4. Clinical results
B. Deep Lamellar Keratoplasty (DLK)
1. Technique
2. Advantages
3. Disadvantage
4. Clinical results
V. Endothelial Keratoplasty (EK)
A. Endothelial Lamellar Keratoplasty (ELK)
B. Posterior Lamellar Keratoplasty (PLK)
1. Technique
2. Advantages
3. Disadvantage
4. Clinical results
C. Deep Lamellar Endothelial Keratoplasty (DLEK)
1. Technique
2. Advantages
3. Disadvantage
4. Clinical results
D. Descemet’s Stripping Endothelial Keratoplasty (DSEK)
1. Technique
2. Advantages
3. Disadvantage
4. Descemet’s stripping automated endothelial lamellar keratoplasty (DSEK)
5. Clinical results
E. Descemet’s Membrane Endothelial Keratoplasty (DMEK)
1. Technique
2. Advantages
3. Disadvantage
4. Clinical results
VI. The Future of Anterior and Endothelial Keratoplasty
VII. References
1. Aggarwal RK. Deep lamellar keratoplasty--an alternative to penetrating keratoplasty. Br J
Ophthalmol 1997;81:178-9.
2. Al-Mezaine H, Wagoner MD; King Khaled Eye Specialist Hospital Cornea Transplant Study
Group. Repeat penetrating keratoplasty: indications, graft survival, and visual outcome. Br J
Ophthalmol 2006;90:324-7.
3. Al-Muammar A, Hodge WG. Donor age as a predictor of cornea transplant success. Can J
Ophthalmol 2005;40:460-6.
4. Al-Yousef N, Mavrikakis I, Mavrikakis E, Daya SM. Penetrating keratoplasty: indications over a
10 year period. Br J Ophthalmol 2004;88:998-1001.
5. Alio JL, Shah S, Barraquer C, et al. New techniques in lamellar keratoplasty. Curr Opin
Ophthalmol 2002;13:224-229.
6. Basak SK. Low endothelial cell count and clear corneal grafts. Indian J Ophthalmol
2004;52:151-3.
7. Beckingsale P, Mavrikakis I, Al-Yousuf N, et al. Penetrating keratoplasty: outcomes from a
corneal unit compared to national data. Br J Ophthalmol 2006;90:728-31.
8. Bourne WM, McLaren JW. Clinical responses of the corneal endothelium. Exp Eye Res
2004;78:561-572.
9. Bourne WM. Cellular changes in transplanted human corneas. Cornea 2001;20:560-569.
10. Branco BC, Gaudio PA, Margolis TP. Epidemiology and molecular analysis of herpes simplex
keratitis requiring primary penetrating keratoplasty. Br J Ophthalmol 2004;88:1285-8.
11. Butler TK, Spencer NA, Chan CC, et al. Infective keratitis in older patients: a 4 year review,
1998-2002. Br J Ophthalmol 2005;89:591-6.
12. Cao KY, Dorrepaal SJ, Seamone C, Slomovic AR. Demographics of corneal transplantation in
Canada in 2004. Can J Ophthalmol 2006;41:688-92.
13. Charukamnoetkanok P. Corneal stem cells: bridging the knowledge gap. Semin Ophthalmol
2006;21:1-7.
14. Coombes AG, Kirwan JF, Rostron CK. Deep lamellar keratoplasty with lyophilised tissue in the
management of keratoconus. Br J Ophthalmol 2001;85:788-91.
15. Coster DJ, Williams KA. The impact of corneal allograft rejection on the long-term outcome of
corneal transplantation. Am J Ophthalmol 2005;140:1112-1122.
16. Culbertson WW. Descemet stripping endothelial keratoplasty. Int Ophthalmol Clin
2006;46:155-168.
17. Dekaris I, Gabric N, Mazuran R, et al. Profile of cytokines in aqueous humor from corneal
graft recipients. Croat Med J 2001;42:650-6.
18. Djalilian AR, Mahesh SP, Koch CA, et al. Survival of donor epithelial cells after limbal stem cell
transplantation. Invest Ophthalmol Vis Sci 2005;46:803-7.
19. Dogru M, Tsubota. Current concepts in ocular surface reconstruction. Semin Ophthalmol
2005;20:75-93.
20. Dorrepaal SJ, Cao KY, Slomovic AR. Indications for penetrating keratoplasty in a tertiary
referral centre in Canada, 1996-2004. Can J Ophthalmol 2007;42:244-250.
21. Edelhauser HF. The resiliency of the corneal endothelium to refractive and intraocular
surgery. Cornea 2000;19:263-273.
22. Faia LJ, Baratz KH, Bourne WM. Corneal graft folds: a complication of deep lamellar
endothelial keratoplasty. Arch Ophthalmol 2006;124:593-595.
23. Feiz V, Mannis MJ, Kandavel G, et al. Surface keratopathy after penetrating keratoplasty.
Trans Am Ophthalmol Soc 2001;99:159-68; discussion 168-70.
24. Fogla R, Padmanabhan P. Initial results of small incision deep lamellar endothelial
keratoplasty (DLEK). Am J Ophthalmol 2006;141:346-351.
25. Frost NA, Wu, J, Lai TF, Coster DJ. A review of randomized controlled trials of penetrating
keratoplasty techniques. Ophthalmology 2006;113:942-949.
26. Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea 2006;25:886889.
27. Hamrah P. High-risk penetrating keratoplasty. Arch Soc Esp Oftalmol 2005;80:5-7.
28. Jain S, Azar DT. New lamellar keratoplasty techniques: posterior keratoplasty and deep
lamellar keratoplasty. Curr Opin Ophthalmol 2001;12:262-268.
29. Kalantan H, Al-Shahwan S, Al-Torbak A. Traumatic globe rupture after deep anterior lamellar
keratoplasty. Indian J Ophthalmol 2007;55:69-70.
30. Kawashima M, Kawakita T, Den S, et al. Comparison of deep lamellar keratoplasty and
penetrating keratoplasty for lattice and macular corneal dystrophies. Am J Ophthalmol
2006;142:304-309.
31. Laibson PR. Current concepts and techniques in corneal transplantation. Curr Opin
Ophthalmol 2002;13:220-223.
32. Loewenstein A, Lazar M. Deep lamellar keratoplasty with complete removal of pathological
stroma for vision improvement. Br J Ophthalmol 1998;82:205.
33. Lord RK, Price FW, Price MO, Werner L, Mamalis N. Histology of posterior lamellar
keratoplasty. Cornea 2006;25:1093-1096.
34. Marchini G, Mastropasqua L, Peddrotti E, et al. Deep lamellar keratoplasty by intracorneal
dissection: a prospective clinical and confocal microscopic study. Ophthalmology
2006;113:1289-1300.
35. Mearza AA, Qureshi MA, Rostron CK. Experience and 12-month results of Descemet-stripping
endothelial keratoplasty (DSEK) with a small-incision technique. Cornea 2007;26:279-283.
36. Melles GRJ. Posterior lamellar keratoplasty: DLEK to DSEK to DMEK. Cornea 2006;25:879881.
37. Melles GRJ, Lander F, Beekhuis WH, et al. Posterior lamellar keratoplasty for a case of
pseudophakic bullous keratopathy. Am J Ophthalmol 1999;127:340-341.
38. Melles GRJ, Lander F, Rietveld FJR, et al. A new surgical technique for deep stromal, anterior
lamellar keratoplasty. Br J Ophthalmol 1999;83:327-333.
39. Melles GRJ, Remeijer L, Geerards AJM, Beekhuis WH. The future of lamellar keratoplasty.
Curr Opin Ophthalmol 1999;10:253-259.
40. Melles GRJ, Song TS, Ververs B, van der Wees J. Descemet membrane endothelial
keratoplasty (DMEK). Cornea 2006;25:987-990.
41. Melles GRJ, Wijdh RHJ, Nieuwendaal CP. A technique to excise the Descemet membrane from
a recipient cornea (Descemetorhexis). Cornea 2004;23:286-288.
42. Minasian M, Ayliffe W. Fixed dilated pupil following deep lamellar keratoplasty (Urrets-Zavalia
syndrome). Br J Ophthalmol 2002;86:115-6.
43. Moffatt SL, Cartwright VA, Stumpf TH. Centennial review of corneal transplantation. Clin
Experiment Ophthalmol 2005;33:642-657.
44. Narayanan R, Gaster RN, Kenney MC. Pseudophakic corneal edema: a review of mechanisims
and treatments. Cornea 2006;25:993-1004.
45. Niederer RL, Perumal D, Sherwin T, McGhee CNJ. Corneal innervation and cellular changes
after corneal transplantation: an in vivo confocal microscopy study. Invest Ophthalmol Vis Sci
2007;48:621-626.
46. Nieuwendaal CP, Lapid-Gortzak R, van der Meulen IJ, Melles GJR. Posterior lamellar
keratoplasty using descemetorhexis and organ-cultured donor corneal tissue (Melles
technique). Cornea 2006;25:933-936.
47. Noble BA, Agrawal A, Collins C, et al. Deep anterior lamellar keratoplasty (DALK): visual
outcome and complications for a heterogeneous group of corneal pathologies. Cornea
2007;26:59-64.
48. Patel N, Mearza A, Rostron CK, Chow J. Corneal ectasia following deep lamellar keratoplasty.
Br J Ophthalmol 2003;87:799-800.
49. Patel SV, Hodge DO, Bourne WM. Corneal endothelium and postoperative outcomes 15 years
after penetrating keratoplasty. Trans Am Ophthalmol Soc 2004;102:57-66.
50. Preschel N, Hardten DR. Management of coincident corneal disease and cataract. Curr Opin
Ophthalmol 1999;10:59-65.
51. Price FW. Corneal transplantation as a refractive surgical procedure. J Refract Surg
2005;21:216-217.
52. Price FW, Price MO. A nonsurgical treatment for donor dislocation after Descemet stripping
endothelial keratoplasty (DSEK). Cornea 2006;25:991.
53. Price FW, Price MO. Descemet’s stripping with endothelial keratoplasty in 200 eyes: early
changes and techniques to enhance donor adherence. J Cataract Refract Surg 2006;32:411418.
54. Price FW, Price MO. Descemet’s stripping with endothelial keratoplasty in 50 eyes: a refractive
neutral corneal transplant. J Refract Surg 2005;21:339-345.
55. Price FW, Price MO. Endothelial keratoplasty to restore clarity to a failed penetrating graft.
Cornea 2006;25:895-899.
56. Price MO, Price FW. Descemet’s stripping with endothelial keratoplasty: comparative
outcomes with microkeratome-dissected and manually dissected donor tissue. Ophthalmology
2006;113:1936-1942.
57. Randleman JB, Stulting RD. Prevention and treatment of corneal graft rejection: current
practice patterns (2004). Cornea 2006;25:286-290.
58. Rao SK Sudhir RR, Fogla R, et al. Bilateral penetrating keratoplasty – indications, results, and
review of literature. Int Ophthalmol 1999;23:161-166.
59. Romaniv N, Price MO, Price FW, Mamalis N. Donor Descemet membrane detachment after
endothelial keratoplasty. Cornea 2006;25:943-947.
60. Sangwan VS, Fernandes M, Bansal AK, et al. Early results of penetrating keratoplasty
following limbal stem cell transplantation. Indian J Ophthalmol 2005;53:31-5.
61. Sano Y. Corneal endothelial transplantation: results of a clinical series using deep lamellar
endothelial keratoplasty (DLEK). Cornea 2004;23(suppl. 1):S55-S58.
62. Saw VPJ, Ng T, Crouch R, Maloof AJ. Deep anterior lamellar keratoplasty using manual
dissection technique of Melles. Cornea 2006;25:882-885.
63. Senoo T, Chiba K, Terada O, et al. Deep lamellar keratoplasty by deep parenchyma
detachment from the corneal limbs. Br J Ophthalmol 2005;89:1597-600.
64. Shimmura S, Miyashita H, Konomi K, et al. Transplantation of corneal endothelium with
Descemet’s membrane using a hyroxyethyl methacrylate polymer as a carrier. Br J
Ophthalmol 2005;89:134-137.
65. Shimmura S, Tsubota K. Deep anterior lamellar keratoplasty. Curr Opin Ophthalmol
2006;17:349-355.
66. Shoshani Y, Pe'er J, Doviner V, et al. Increased expression of inflammatory cytokines and
matrix metalloproteinases in pseudophakic corneal edema.
Invest Ophthalmol Vis Sci 2005;46:1940-7.
67. Singh R, Umapathy T, Kulkarni BB, Dua HS. Corneal epithelial defects related to high
postoperative astigmatism. Br J Ophthalmol 2005;89:1373-4.
68. Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma
for vision improvement. Br J Ophthalmol 1997;81:184-188.
69. Suwan-apichon O, Rizen M, Reyes JMG, et al. A new donor cornea harvesting technique for
posterior lamellar keratoplasty. Br J Ophthalmol 2005;89:1100-1101.
70. Tan BU, Purcell TL, Torres LF, Schanzlin DJ. New surgical approaches to the management of
keratoconus and post-LASIK ectasia. Trans Am Ophthalmol Soc 2006;104:212-20.
71. Terry MA, Hoar KL, Wall J, Ousley P. Histology of dislocations in endothelial keratoplasty
(DSEK and DLEK): a laboratory-based, surgical solution to dislocation in 100 consecutive
DSEK cases. Cornea 2006;25:926-932.
72. Terry MA, Ousley PJ. Deep lamellar endothelial keratoplasty: early complications and their
management. Cornea 2006;25:37-43.
73. Terry MA, Ousley PJ. Deep lamellar endothelial keratoplasty: visual acuity, astigmatism, and
endothelial survival in a large prospective series. Ophthalmology 2005;112:1541-1549.
74. Terry MA. A new approach for endothelial transplantation: deep lamellar endothelial
keratoplasty. Int Ophthalmol Clin 2003;43:183-193.
75. Terry MA. Deep lamellar endothelial keratoplasty (DLEK): pursuing the ideal goals of
endothelial replacement. Eye 2003;17:982-988.
76. Terry MA. Endothelial keratoplasty: history, current state, and future directions. Cornea
2006;25:873-878.
77. Terry MA. The evolution of lamellar grafting techniques over twenty-five years. Cornea
2000;19:611-616.
78. Vajpayee RB, Agarwal T, Jhanji V, Sharma N. Modification in Descemet-stripping automated
endothelial keratoplasty: “hitch suture” technique. Cornea 2006;25:1060-1062.
79. Van Dooren B, Mulder PGH, Nieuwendaal CP, et al. Endothelial cell density after posterior
lamellar keratoplasty (Melles techniques): 3 years follow-up. Am J Ophthalmol
2004;138:211-217.
80. van Rij G, Bartels M. Descemet’s stripping with endothelial keratoplasty in 50 eyes: a
refractive neutral corneal transplant. J Refract Surg 2006;22:529-530.
81. Vanathi M, Sharma N, Sinha R, et al. Indications and outcome of repeat penetrating
keratoplasty in India. BMC Ophthalmol 2005;5:26.
82. Watson SL, Tuft SJ, Dart JKG. Patterns of rejection after deep lamellar keratoplasty.
Ophthalmology 2006;113:556-560.
83. Yamada M. Overcoming the technical challenges of deep lamellar keratoplasty.
Br J Ophthalmol 2005;89:1548-9.
84. Yuta K, Kami M, Matsumoto Y, et al. Deep lamellar keratoplasty for corneal perforation due to
chronic graft-versus-host disease following allogeneic hematopoietic stem-cell transplantation.
Haematologica 2005;90(3):ECR15.