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Brief Report |

In Vivo Effects of Femtosecond Laser–Assisted Keratoplasty ONLINE FIRST

Michael Banitt, MD1; Florence Cabot, MD1; Rehan Hussain, MD1; Sander Dubovy, MD1; Sonia H. Yoo, MD1
[+] Author Affiliations
1Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
JAMA Ophthalmol. Published online July 31, 2014. doi:10.1001/jamaophthalmol.2014.2389
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Importance  The femtosecond laser is reported to cut lamellar surfaces with varying degrees of smoothness depending on the depth of the cut, with deeper cuts leaving less smooth surfaces. We attempted to evaluate the smoothness of the deeper lamellar surface as cut by the femtosecond laser after allowing 3 months of in vivo healing.

Observations  Two patients underwent penetrating keratoplasty 3 months after inadequate visual rehabilitation following femtosecond laser–assisted sutureless anterior lamellar keratoplasty for the treatment of anterior stromal scars. In vivo confocal microscopy that was performed before penetrating keratoplasty demonstrated an acellular zone with a hyperintense signal consistent with a mild interface opacification. Light microscopy in one patient demonstrated scarring limited primarily to the posterior stroma; in the other patient, the interface was smooth with mild scarring of the anterior lamellae. When studied with electron microscopy, the cut surfaces revealed a smooth to very mild stuccolike appearance that was smoother than anticipated.

Conclusions and Relevance  After 3 months of in vivo healing, the lamellar interface produced by the femtosecond laser, as imaged by electron microscopy, appeared to be nearly smooth with minimal roughness to the cut surfaces. We attribute this to the effects of in vivo healing and remodeling.

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Figure 1.
In Vivo Confocal Microscopy of Donor/Host Interface Prior to Penetrating Keratoplasty in Case 1

In vivo confocal microscopy revealed a hyperintense signal consistent with mild interface scarring.

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Figure 2.
Light Microscopy With Ki-67 Staining and Smooth-Muscle Actin (SMA) of Donor/Host Interfaces After Penetrating Keratoplasty in Case 2

A, Donor/host interface after penetrating keratoplasty. Light microscopy with Ki-67 staining (original magnification x200) did not show significant cellular proliferation close to the donor/host interface even if we noticed that the density of keratocytes was higher in the posterior stroma than in the anterior stroma. Ki-67 staining was also negative in case 1. B, Light microscopy with SMA staining (original magnification x200) did not reveal significant myofibroblastic contraction that could have explained the stuccolike aspect found in electron microscopy. The SMA staining was also negative in case 1.

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Figure 3.
Light Microscopy of the Donor/Host Interface After Penetrating Keratoplasty in Cases 1 and 2

Donor/host interface after penetrating keratoplasty in case 1 (A) and case 2 (B). Light microscopy (hematoxylin-eosin, original magnification x100) showed mild interface scarring in both cases. The arrowheads denote the interface between the anterior and posterior lamellae. In case 1 (A), the asterisk shows that the scarring was mainly located in the posterior stroma (residual stromal bed after femtosecond laser–assisted lamellar keratoplasty). In case 2 (B), the interface was smooth with mild scarring located in the anterior lamellae. The trephination edge was regular with no epithelial ingrowth (B).

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Figure 4.
Electron Microscopy of the Donor Posterior Surface and Recipient Anterior Surface in Case 1

Electron microscopy of donor posterior surface (A, original magnification [Magn] ×305) and recipient anterior surface (B, original Magn ×328) showed a mild stuccolike appearance in both the donor and recipient corneal lamellar surfaces. Acc. V indicates acceleration voltage; Det, detector; Exp, exposure; GSE, gaseous secondary electron; and WD, working distance.

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