Ultrastructural Alterations of Grafted Corneal Buttons: Stud
A Study was conducted to examine the ultrastructure of the natural plane of separation in grafted corneas and evaluate the outcomes of stromal peeling.

In this multicenter study, stromal peeling was attempted in 96 consecutive eyes with unsatisfactory vision following penetrating keratoplasty (PK) for keratoconus(n=79), herpetic keratitis(n=11) and granular dystrophy(n=6).

Stromal exchange was performed by:
1) 9mm partial-thickness trephination;
2) Creation of a corneal flap across the PK wound;
3) Opening of the stromal component of the PK wound until a smooth, translucent natural plane was identified;
4) Severing the attachment of the PK scar;
5) Stromal peeling along the identified plane;
6) Suturing of donor lamella.
Grafted corneas from cases which mandated conversion to PK were processed for transmission electron microscopy.

Results:
--The natural plane of separation was identified in all cases.

--Stromal exchange was successfully completed in 84 cases. Snellen visual acuity more than 20/40 and more than 20/25 was reached in 93% and 72% of cases at 3 years and 86% and 62% at 4 years postoperatively.

--Mean endothelial cell loss at 1 year was 6.6±9.5%. Stromal peeling occurred along a plane lined with a continuous layer of keratocytes separating pre-Descemet membrane (DM) stroma, DM and endothelium from the anterior stroma.

Ultrastructural changes in the stromal microarchitecture of grafted corneas shows, an intra-operatively determined natural separation plane. Stromal peeling can be successfully performed in post-PK eyes with various stromal pathology.

Source: https://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886-021-02001-6
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