Jpn J Ophthalmol 2011;55:9397

Japanese Ophthalmological Society 2011

DOI 10.1007/s10384-010-0914-x

CLINICAL INVESTIGATION

Comparison of Refractive Changes After Deep

Anterior Lamellar Keratoplasty and Penetrating
Keratoplasty for Keratoconus
Kuk-Hyoe Kim, Sung-Ho Choi, Kyeon Ahn, Eui-Sang Chung,
and Tae-Young Chung
Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of
Medicine, Seoul, Korea

Abstract
Purpose: To compare refractive changes occurring after deep anterior lamellar keratoplasty (DALK) or
penetrating keratoplasty (PKP) in patients with keratoconus.
Methods: We retrospectively reviewed the medical records of 57 patients with keratoconus who received
DALK (19 eyes of 19 patients) or PKP (38 eyes of 38 patients) before and after surgery between January
1996 and January 2008, in an effort to evaluate the surgical results and clinical courses. The principal
outcome measures were as follows: preoperative and postoperative uncorrected visual acuity (UCVA),
best-corrected visual acuity (BCVA), manifest refraction, and corneal topography including anterior
chamber depth (ACD).
Results: We noted no significant difference between the DALK and PKP groups in terms of postoperative UCVA, BCVA, astigmatism, or donorrecipient graft size disparities. For the PKP and DALK groups,
the mean postoperative spheres were 1.64 D and 4.29 D at 6 months (P = 0.01) and 2.73 D and
4.22 D at 12 months, respectively (P = 0.04). Postoperative mean central corneal powers (3.0/5.0 mm
zone) were 45.01/45.03 D and 46.94/47.84 D, respectively (P = 0.04 and P = 0.02). ACD after surgery was
3.25 and 3.37 mm at the final follow-up, respectively (P = 0.02).
Conclusions: Although DALK is a safe alternative in cases of keratoconus, the DALK group evidenced
significantly higher myopia than did the PKP group, which was related to steeper central corneal power
and deeper ACD. Jpn J Ophthalmol 2011;55:9397 Japanese Ophthalmological Society 2011
Keywords: anterior chamber depth, deep anterior lamellar keratoplasty, keratoconus, keratometry,
penetrating keratoplasty

Introduction
Keratoconus is one of the most frequently observed indications for corneal transplantation. The principal aim of
corneal transplantation is to achieve a functioning transpar-

Received: March 17, 2010 / Accepted: October 14, 2010

Correspondence and reprint requests to: Tae-Young Chung, Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan
University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul
135-710, South Korea
e-mail: tychung@skku.edu
A shorter version of this paper was presented as a poster at the Korean
Ophthalmological Society 97th Spring Meeting, April 2007, Pusan,
Korea.

ent corneal graft with a minimal refractive error and to

maximize the patients postoperative visual function,
although attaining an optimal visual outcome has proven to
be challenging. Unpredictable spherical errors after grafting
for keratoconus render it quite difficult to improve or
predict uncorrected visual acuity. Hence, in our study, a
great deal of attention was focused on postoperative refractive errors.
Penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) are standardized surgical options
for patients with keratoconus. However, surgeons in general
do not take into account the difference in refractive outcomes between the two procedures. While several reports
have described the clinical outcomes of PKP and DALK
in keratoconic patients, reports of clinical results that

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Jpn J Ophthalmol
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focus on the refractive difference between the two surgical

procedures are few, including a case series from our
department.18
In this study, we retrospectively reviewed the clinical
records of keratoconic patients who underwent either standard PKP or DALK, and we compared the refractive
changes of the two groups, including the central corneal
power and anterior chamber depth (ACD), and analyzed
the factors that might have influenced these refractive
changes. To the best of our knowledge, this is the first study
to attempt to evaluate the potential factors influencing the
refractive results after PKP and DALK surgery.

Participants and Methods

Participants
The medical records of 57 eyes of 57 patients diagnosed as
having keratoconus who underwent PKP (n = 38 eyes) or
DALK (n = 19 eyes) from January 1996 to January 2008 at
Samsung Medical Center by two surgeons (E.S. Chung and
T.Y. Chung) were retrospectively reviewed. All patients
required a minimum follow-up of 1 year. The patients had
either become intolerant of contact lens wear or had bestcorrected visual acuity (BCVA) of 0.5 or worse at the time
of the surgery. Any eyes that converted to PKP as a result
of Descemet membrane rupture during the DALK procedure were included in the PKP group.

groups, a Hessburg-Barron trephine (Katena Products,

Denville, NJ, USA) was used, and the size of the donor
trephine was 0.25 mm larger than that of the recipient trephine. Upon completion of the surgeries, the sutures were
adjusted by means of a Maloney keratometer (Katena
Products) to minimize the degree of astigmatism.

Assessment and Measurement Variables

BCVA and manifest refraction [sphere, cylinder, and spherical equivalent (SE)] were measured at the time of surgery
and again at 6 and 12 months postoperatively. Corneal
topographies [Sim K astigmatism, 3.0/5.0-mm zone mean
power, and anterior chamber depth (ACD)] were measured
and compared using an ORBscan II (Bausch & Lomb,
Rochester, NY, USA) at 12 months postoperatively. The
preoperative and postoperative data were collected by a
single technician.

Statistical Analysis
Statistical data were acquired using PASW 17.0 (SPSS,
Chicago, IL, USA). As the group distributions were nonGaussian, uncorrected visual acuity (UCVA) and BCVA
[logarithm of the minimum angle of resolution (logMAR)],
manifest refraction (sphere, cylinder, and SE), and corneal
topography (Sim K astigmatism, 3.0/5.0-mm zone mean
power, and ACD) were compared using the Mann-Whitney
test.

Surgical Method
DALK with a variant of Anwars big-bubble technique
under general anesthesia was conducted.9,10 The prepared
donor graft was placed on the recipients cornea and fixed
securely with eight interrupted sutures and one continuous
suture using 10-0 nylon. Before finishing the surgical procedure, we injected air into the anterior chamber to accelerate
the adhesion between the Descemet membrane and the
grafted corneal stroma. After the surgery, the patients
received antibiotic eyedrops (Cravit; Santen, Osaka, Japan)
four times daily and artificial tears (Refresh Plus; Allergan,
Irvine, CA, USA) six times daily. Thereafter, they received
1.0% prednisolone acetate eyedrops (Pred Forte; Allergan)
six times daily for 2 months and then 0.1% fluorometholone
solution (Flumetholon, Santen) four times daily for the final
10 months. Oral prednisolone (Solondo; Yuhan, Seoul,
Korea) was started at 30 mg per day, and the dose was
gradually lowered over 6 weeks. The patients were periodically monitored on an outpatient basis. Suture removal was
started at 6 months and completed by 12 months after the
surgery.
Standard PKP under general anesthesia was conducted
with suturing performed in the same fashion as for DALK.
Postoperative medication, suture removal, and outpatientbased observation were also conducted in the same manner
as for the DALK procedure. In both the PKP and DALK

Results
Demographic Data
The average age at the time of the operation of patients
undergoing DALK or PKP was 25.3 years (range, 1746
years) and 26.2 years (range, 1251 years), whereas the
mean follow-up period was 22.6 months (range, 1234
months) and 51.7 months (range, 12115 months), respectively (Table 1). We noted no differences in baseline characteristics between the treatment groups, with the exception
of the follow-up period. The median follow-up period for
PKP patients was statistically longer than that for DALK
patients (P < 0.01). To overcome the difference in follow-up
times, we compared the two groups at the 6- and 12-month
follow-ups.

Graft Size
The mean diameters of the donor corneas in the PKP and
DALK groups were 8.00 0.20 mm (range, 7.758.0 mm)
and 8.04 0.23 mm (range, 7.758.0 mm), respectively,
whereas the mean diameters of the recipient corneas were
7.75 0.20 mm (range, 7.507.75 mm) and 7.79 0.23 mm

K.-H. KIM ET AL.

REFRACTIVE CHANGES AFTER DALK AND PKP FOR KERATOCONUS

(range, 7.507.75 mm), respectively. The disparity between

the donor and recipient trephine sizes was 0.25 mm in all
patients; thus, we detected no significant difference between
the two groups.

95

DALK group. Significant spherical differences were found,

but not astigmatism differences, at 12 months postoperatively (P = 0.04, P = 0.34) (Table 2).

Corneal Topography
Visual Acuity
No significant differences were detected between the two
groups in terms of BCVA (logMAR), which was measured
prior to surgery and at 6 and 12 months postoperatively
(Fig. 1). Thirty-three of the 38 patients in the PKP group
(86.8%) and 16 of the 19 patients in the DALK group
(84.2%) achieved a BCVA of 6/12 or better at 12 months
postoperatively; thus, the differences were not statistically
significant (P = 0.86).

Corneal topography determined at 12 months postoperatively showed that central corneal power in the DALK
group was significantly higher in both the 3-mm and 5-mm
zones (P = 0.04 and P = 0.02, respectively), whereas no
significant differences were detected in astigmatism (P =
0.28) (Table 3). ACD was significantly deeper in eyes of the
DALK group than in those of the PKP group (P = 0.02)
(Fig. 2).

Discussion
Manifest Refraction
Postoperative measurement of the refractive sphere at 6
months evidenced significantly higher myopia (P = 0.01) as
well as significantly lower astigmatism (P = 0.04) in the

Table 1. Demographic data of keratoconic patients who

underwent DALK or PKP

Number of patients
Male : female
Right : left
Age at operation
(range)
Follow-up (range)

DALK

PKP

19
17 : 2
12 : 7
25.3 years (1746)

38
25 : 13
15 : 23
26.2 years (1251)

22.6 months
(1234)

51.7 months
(12115)

DALK, deep anterior lamellar keratoplasty; PKP, penetrating

keratoplasty.

Until recently, PKP has been considered the standard surgical method for the treatment of keratoconus. However,
graft rejection of the corneal endothelial layer occurs at a
rate of 20% to 30% during the postoperative period and is
becoming the most salient reason for the failure of cornea
transplantation.11 DALK, which was initially introduced by
Archila in 1985,12 has been presented as an alternative surgical method to PKP in the treatment of a variety of corneal
diseases, such as keratoconus, dystrophies, degenerations,
trauma, and microbial keratitis, when there is no intrusion
of the corneal endothelium. This surgical technique replaces
the diseased corneal layer with a healthy donor cornea and
achieves improvement in vision and has potential advantages over PKP in terms of a reduction in the incidence of
rejection episodes at the corneal endothelium, preservation
of endothelial cells, stronger grafthost junction, and shorter
postoperative rehabilitation.1,6,9 However, the principal limitation of DALK involves the technical difficulties in the

Figure 1. Change of logarithm of

the minimum angle of resolution
(logMAR) best-corrected visual
acuity (BCVA) after deep anterior
lamellar keratoplasty (DALK) and
penetrating keratoplasty (PKP).
Mean BCVAs preoperatively and
including the last follow-up are
provided. There were no statistical
differences in BCVA between the
DALK and PKP groups throughout the observation period (P >
0.05). The mean follow-up was
22.6 months (range, 1234 months)
and 51.7 months (range, 12115
months), respectively. The results
are expressed as the mean BCVA
SD. = PKP; = DALK.

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Jpn J Ophthalmol
Vol 55: 9397, 2011

Table 2. Refractive data obtained from keratoconic patients 6 and 12 months after DALK or PKP
Postop 6 months

DALK
PKP
P value

Postop 12 months

SE

Dsph

Dcyl

SE

Dsph

Dcyl

6.28 3.62
3.91 3.37
0.04

4.29 3.88
1.64 3.83
0.01

2.72 2.08
4.54 3.02
0.04

6.54 4.16
4.90 4.05
0.09

4.22 4.56
2.73 3.81
0.04

4.55 3.34
4.36 3.06
0.34

Values other than P values represent means SD.

SE, diopter spherical equivalent; Dsph, diopter sphere; Dcyl, diopter cylinder; SD, standard deviation.

Table 3. Topographic data obtained from keratoconic

patients 12 months after DALK or PKP
TOPO

DALK (D)

PKP (D)

P value

Postop Sim K astig

Postop 3.0 mean pwr
Postop 5.0 mean pwr

5.41 4.99
46.94 4.37
47.84 5.37

4.17 2.36
45.01 3.80
45.03 4.65

0.28
0.04
0.02

TOPO, topographic data; D, diopters; astig, astigmatism; pwr, power.

Figure 2. Comparison of anterior chamber depth (ACD) between the

PKP (3.25 0.29 mm) and DALK (3.37 0.28 mm) groups at 12
months postoperatively. The DALK group showed a significantly
deeper anterior chamber than did the PKP group (P = 0.02). The results
are expressed as the mean ACD SD.

surgical procedure, along with the possibility of a prolonged

surgical procedure and complications associated with the
grafthost interface.6 Recently, Bahar et al.7 reported
that DALK and PKP provide comparable visual outcomes,
although DALK results in a significantly higher level of
high-order and tilt aberrations.
In this study, we noted a trend toward a higher degree of
myopia in the DALK group than in the PKP group. The
respective mean postoperative SEs for the DALK and PKP
groups were 6.28 3.62 D and 3.91 3.37 D at 6 months
and 6.54 4.16 D and 4.90 4.05 D at 1 year. Watson et
al.1 reported a median SE of 4.13 D [interquartile range
(IQR), 5.0 to 2.0] in the DALK group, compared with

1.63 D (IQR, 4.0 to 2.25) in the PKP group. Similarly,

Funnell et al.2 reported higher myopia in the DALK group
than in the PKP group, with a median SE of 3.0 D (range,
15.5 to 0.63) compared with 1.0 D (range, 9.5 to 9.0) in
the PKP group. But other studies have reported much lower
myopic refraction after DALK using the same big-bubble
technique. Coombes et al.3 reported an average of only
1.65 D of SE (range, 10.25 to +7.0) in eyes after DALK.
Bahar et al.7 reported that the mean final SE power in both
groups was less than 1 D when the donor and recipient
trephines were of the same diameter. A higher myopic
refractive outcome after DALK in this study might be
attributable to the use of an oversized (0.25 mm) donor
button, which may have resulted in the higher corneal curvature and ACD after DALK.
Potential factors that might influence the results of manifest refraction after corneal transplantation include disparity in the size of the donor and recipient trephines and
suture techniques, in addition to preoperative ametropia.
Perry and Foulks13 and Wilson and Bourne14 demonstrated
a reduction in the degree of postoperative myopia at followup using donor trephines of the same size, but Jaycock et
al.15 reported that myopia was not reduced in cases in which
the donor and recipient trephines were the same size. In this
study, the disparity in trephine size was 0.25 mm, and the
same suture technique was applied in all cases; thus, a
possible influence of these two factors can be excluded.
However, the degree of preoperative ametropia could not
be evaluated owing to poor refraction in the advanced keratoconic eyes, which is a limitation of this study.
Klein et al.16 reported that SE was inversely correlated
with axial length (r = 0.45) and ACD (r = 0.10) but positively correlated with corneal curvature (r = 0.19). In our
study, postoperative ACD was significantly deeper (3.37
0.28 mm versus 3.25 0.29 mm; mean difference, 0.12 mm)
and the central corneal power significantly steeper (46.94
4.37 D versus 45.01 3.80 D; mean difference, 1.93 D) in
the eyes of the DALK group than in those of the PKP group
at 12 months postoperatively, which should have resulted in
a higher degree of myopia in the DALK group eyes. According to Olsen,17 1.0 mm of ACD difference and 1 D of central
corneal power difference result in refractive differences of
1.5 D and 0.9 D, respectively. Interestingly, the true difference in mean SE between the two groups (6.54 4.16 D
and 4.90 4.05 D; difference, 1.64 D) was comparable
to the theoretically calculated mean refractive difference
(1.89 D).

K.-H. KIM ET AL.

REFRACTIVE CHANGES AFTER DALK AND PKP FOR KERATOCONUS

This difference in ACD and central corneal power may

be associated with the surgical characteristics of DALK and
PKP. Since DALK is performed as a closed-system surgery,
anterior chamber collapse is avoided and the peripheral
angle should be wider during the suture, resulting in a
relatively deeper ACD and steeper central corneal
power. However, because PKP is an open-system surgery, it
results in a shallower ACD and more flattened cornea as a
result of the collapse of the anterior chamber angle. Another
possibility is the lack of endothelial scarring in DALK,
which in the case of PKP may act as a reinforcement ring
to prevent steepening of the donor cornea. To the best of
our knowledge, no previous reports have discussed the
influence of topographic data and ACD on the postoperative tendency toward myopia in DALK surgery.
In conclusion, this was one of the largest retrospective
comparative studies ever conducted regarding the potential
factors (specifically including topographic data and ACD)
influencing postoperative refractive errors in DALK and
PKP patients. Postoperative visual acuity and astigmatism
were comparable between the two groups. However, the
DALK group evidenced a significantly higher degree of
myopia than did the PKP group. This difference may be
attributed partially to the significantly deeper ACD and
steeper central corneal power in the DALK group, which is
attributable to the unique closed-system surgical characteristics of DALK. When planning for DALK surgery in keratoconic patients, surgeons should take into account the
higher tendency toward postoperative myopia.

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