• Muhammad Abdul Moqeet, Warda Ali, Saad Alam Khan, Aruba Zafar, and Hassan Mansoor.
• Department of Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan.
• J Coll Physicians Surg Pak. 2022 Sep 1; 32 (9): 1160-1164.

ObjectiveTo determine the one-year visual and refractive outcomes of deep anterior lamellar keratoplasty (DALK) in patients with advanced keratoconus (KC) using inexpensive readily available instruments.Study DesignAn observational study.Place And Duration Of StudyDepartment of Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, from November 2016 to March 2021.MethodologyThe authors evaluated different types of big bubble (BB) formation and the conversion rate of intended DALK (n=120) to the penetrating keratoplasty (PK) in patients with grade 4 KC. For analysis, only those patients were included in whom DALK was completed. Main outcome measures at 1-year follow-up were best-corrected visual acuity (BCVA), maximum keratometry (Kmax) reading, spherical equivalent (SE), and topographic astigmatism (TA). All the postoperative complications were recorded.ResultsType 1 BB was formed in 68% (n=82) of the patients. An incomplete type 1 BB and type 2 BB were observed in twenty and eighteen patients, respectively. DALK was completed successfully in 102 patients. Whereas, the conversion rate to PK was 15% (n=18). The mean preoperative BCVA improved from 1.11±0.23 logMAR to 0.46±0.20 logMAR, at 1-year follow-up. The mean Kmax, SE, and TA readings reduced from a preoperative value of 62.1±4.60 D, -11.6±2.62 D, and 4.63±1.82 D, respectively, to 49.1±3.10 D, -5.65±0.84 D, and 2.78±1.35 D, respectively, at 1-year follow-up. Stromal rejection was recorded in two patients, but it responded well to topical therapy.ConclusionInexpensive readily available instruments can be used to perform DALK in patients with advanced KC with favourable visual and refractive outcomes.Key WordsBig bubble, Deep anterior lamellar keratoplasty, Keratoconus, Perforation, Penetrating keratoplasty.

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