Anterior Lamellar Keratoplasty (ALK) is partial thickness corneal transplant surgery for the treatment of keratoconus and other corneal conditions, including superficial scarring, which affect the anterior layers of the cornea. In this procedure, the affected layers of the cornea are transplanted, while the innermost layers remain intact. During this surgical procedure, using the Anwar’s “big bubble” technique, the diseased corneal stroma is dissected and removed, leaving Descemet’s membrane and the recipient’s healthy endothelium intact. Traditionally, penetrating keratoplasty (PK), which involves a full thickness corneal graft, has been the choice for treatment for conditions affecting all layer of the cornea. PK, however, can be complicated by graft rejection, irregular astigmatism and corneal opacification, resulting in visual impairment. ALK offers an alternative treatment that may lessen those risks because the Descemet’s membrane and endothelium are preserved, thereby essentially eliminating any risk of endothelial rejection (most common type of graft rejection).
There are significant advantages to the ALK operation compared to the standard corneal transplant operation. These advantages are associated with the surgeon’s ability to program the exact depths required for complete stromal removal while leaving the Descemet’s membrane intact. These advantages include 1.) Stronger wound, whereas the integrity of the endothelium is maintained, thus keeping the eye intact and reducing vulnerabilities normally associated with corneal transplantation, 2.) preservation of the globe integrity, 3.) potentially faster recovery, 4.) possible reduction of overall astigmatism with earlier removal of sutures allowing for faster results and 5.) longer graft survival.
ALK is not for everyone. Patients may have other ocular pathologies or conditions making them not suitable candidates for ALK. Additionally, there are risks involved with the ALK operation. The procedure is technically challenging and there is a potential for interface scarring (and reduced visual clarity). This technique requires overcoming the challenge of knowing how to go deep enough without cutting through Descemet’s membrane. Leaving a portion of the stroma may cause a reduction in best-corrected acuity by the recipient.
Visual recovery after transplant surgery (partial and full-thickness transplantation) is typically 6 months to 1 year. During the initial 1-2 weeks post-operative phase, patients may experience a foreign body sensation and fluctuating vision while the eye is recovering. Patients will take antibiotic drops for the first 1-2 weeks and take anti-inflammatory drops for several months or longer. The usual time for suture removal begins around the third month after surgery. Visual recovery after ALK +/- IEK may be somewhat quicker whereas sutures are removed sooner.
Dr. Hatch is now offering Intralase Enabled Keratoplasty (IEK) which applies femtosecond laser technology to perform the incision for corneal transplant surgery at Talamo Hatch Laser Eye Consultants. At TLEC, we highly recommend utilization of the femtosecond laser when undergoing the ALK or PKP procedure. Please discuss this option with Dr. Hatch at your consultation.
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