Vishal Jhanji, MD 1,2 Jacqueline Beltz, MBBS, FRANZCO 2 Sonia Moorthy, MBChB 2

1. “Tuck In” Lamellar Keratoplasty (TILK) for Post-Keratoplasty Corneal Ectasia involving the Corneal Periphery Vishal Jhanji, MD1,2 Jacqueline Beltz, MBBS,FRANZCO2 Sonia Moorthy, MBChB2 Rasik B Vajpayee, MS, FRCS (Edin), FRANZCO2 1The Chinese University of Hong Kong 2Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Australia The authors have no financial interest in the subject matter of this poster

2. BACKGROUND • Post-keratoplasty corneal ectasia has been known to occur many years after the primary surgery in cases with keratoconus • The ectasia as well as thinning may involve the donor, graft host junction or the host tissue beyond the graft host junction, causing severe astigmatism and irregular corneal contour, making contact lens fitting very difficult

3. PURPOSE • Repeat penetrating keratoplasty (PKP) involves use of a larger graft and its inherent complications like glaucoma and increased risk of endothelial rejection • We describe Tuck-In Lamellar Kertaoplasty (TILK) for the surgical management of cases with post-PKP corneal ectasia beyond the graft-host junction

4. METHODS • Retrospective chart review was conducted for all patients with that underwent TILK for post-PKP ectasia at the Royal Victorian Eye and Ear Hospital, Melbourne • Data collected included preoperative and postoperative UCVA, BCVA, endothelial cell density, keratometry, and endothelial cell density

5. METHODS: SURGICAL TECHNIQUE Donor Preparation • A Hessburg Barron vacuum trephine was used to make an initial partial thickness groove of 200-250 microns. The anterior lamellar disc was excised and a pocket was made circumferentially in the corneal periphery up to 0.5 mm posterior to the limbus Preparation of graft • An initial partial thickness incision up to a depth of 300 microns was made using a 9-9.5 mm trephine followed by a lamellar dissection peripheral to the trephine cut. Donor lenticule consisting of central 9-9.5 mm full-thickness graft with a peripheral partial thickness flange of about 2.0 mm was fashioned

6. “TUCK IN” LAMELLAR KERATOPLASTY Flange of donor lenticule was tucked into peripheral intrastromal pocket of host

7. RESULTS

8. RESULTS • TILK was performed in four eyes of 3 patients with post-PKP corneal ectasia beyond the graft host junction • The original indication for penetrating keratoplasty was keratoconus • Average number of years since the original surgery was 25 ±13.63 (range: 10 to 43 years) • The mean age of the patients was 34.3 (SD 11.84) years

9. RESULTS • Mean follow-up period was 13 months (SD 7.74) (range 6-24 months) • All the grafts were clear at the last follow-up visit and there was no evidence of ectasia • Postoperatively, the UCVA, BCVA and keratometry improved significantly (p<0.05) [Table]

10. RESULTS (Average values)

11. CONCLUSIONS • TILK can be successfully performed for post-penetrating keratoplasty corneal ectasia with peripheral corneal thinning

12. IMPORTANT READINGS • Abelson M, Collin H, Gillette T, et al. Recurrent keratoconus after keratoplasty. Am J Ophthalmol 1980; 90:672–676 • Kaushal S, Jhanji V, Sharma N, et al. "Tuck In" Lamellar Keratoplasty (TILK) for corneal ectasias involving corneal periphery. Br J Ophthalmol 2008; 92:286-90 Correspondence Prof Rasik B Vajpayee, MS, FRCS (Edin), FRANZCORoyal Victorian Eye and Ear Hospital Centre for Eye Research Australia, University of Melbourne32, Gisborne Street, East MelbourneVictoria 3002, AustraliaTel: 61 3 9929 8368Fax: 61 3 9662 3959 Email: rasikv@unimelb.edu.au