Dual laser-assisted lamellar anterior keratoplasty with top hat graft: A laboratory study

OBJECTIVES: To develop a dual laser-assisted lamellar anterior keratoplasty (LALAK) technique, using excimer and femtosecond lasers to perform surgery on eye bank eyes. METHODS: First, we compared corneal stromal surfaces produced by (1) deep excimer ablation, (2) femtosecond lamellar cuts, and (3) manual dissection and evaluated the effect of excimer laser smoothing with fluid masking on each surface. Masked observers graded scanning electron microscopy images on a 5-point roughness scale. Then, we performed a 6-mm diameter excimer laser phototherapeutic keratectomy ablation to a residual bed thickness of 200 μm, followed by laser smoothing. We used the femtosecond laser to cut donors in a modified top hat design with a thin tapered brim, which fitted into a manually dissected circumferential pocket at the base of the recipient bed. Fourier domain optical coherence tomography was used to measure corneal pachymetry and evaluate graft fit. RESULTS: Deep excimer ablation with smoothing (n = 4) produced a significantly (P < 0.05) smoother surface (grade = 3.5) than deep excimer alone (n = 4, grade = 3.8) or manual dissection with (n = 1, grade = 3.8) and without smoothing (n = 1, grade = 4.8). Deep femtosecond cuts (n = 2) produced macroscopic concentric ridges on the stromal surface. Experimental LALAK was performed on 4 recipients prepared by deep excimer ablation and 4 donors cut with the femtosecond laser. After suturing, good peripheral graft-host match was observed on Fourier domain optical coherence tomography imaging. CONCLUSION: These preliminary studies show that the LALAK technique permits improved interface smoothness and graft edge matching. Clinical trials are needed to determine whether these improvements can translate to better vision.