Posterior lamellar keratoplasty / deep lamellar endothelial keratoplasty (PLK/DLEK)

Topic II.2.b – Posterior lamellar keratoplasty / deep lamellar endothelial keratoplasty (PLK/DLEK)

In endothelial disorders, the inner layer of the cornea is affected. Sofar, replacement of the endothelium could only be achieved by performing a full-thickness penetrating keratoplasty (PK) in which all corneal layers are transplanted. Given the frequent occurrence of complications in the surgical aftercourse, the final visual performance of the graft was often poor.

In 1996, the NIIOS R&D developed a surgical method to selectively excise the posterior stromal layers and to implant a donor posterior disk through a 9.0 mm scleral incision. This technique, a posterior lamellar keratoplasty, was later popularized in the United States as ‘Deep lamellar endothelial keratoplasty’ (DLEK). Although a prototype technique, the clinical results after PLK/DLEK improved dramatically as compared to a PK.

Prior art

• Tillet CW. Posterior lamellar keratoplasty Am J Ophthalmol 1956;41:530-533.
• Polack FM. Queratoplastia Lamelar Posterior. Revista Peruana de Oftalmologia 1965;2:62-64.
• The technique for penetrating keratoplasty. In: Barraquer J, Rutllán J (eds): Microsurgery of the cornea. An atlas and textbook. Barcelona, Ediciones scriba, 1984:289-294.
• McCulley JP, Maurice DM, Schwartz BD: Corneal endothelial transplantation. Ophthalmology 1980;87:194-201.
• Mohay J, Lange TM, Soltau JB, Wood TO, McLaughlin BJ: Transplantation of corneal endothelial cells using a cell carrier device. Cornea 1994;13:173-182.
• Ko WW, Frueh BE, Shields CK, Costello ML, Feldman ST: Experimental posterior corneal transplantation of the rabbit cornea. Invest Ophthalmol Vis Sci 1993;34(suppl):1967.

NIIOS Contributions

• Melles GRJ, Eggink FAGJ, Lander F, Pels E, Rietveld FJR, Beekhuis WH, Binder PS: A surgical technique for posterior lamellar keratoplasty. Cornea 1998;17:618-626.
• Melles GRJ, Lander F, Beekhuis WH, Remeijer L, Binder PS: Posterior lamellar keratoplasty for a case of pseudophakic bullous keratopathy. Am J Ophthalmol 1999;127:340-341.
• Melles GRJ, Remeijer L, Geerards A, Beekhuis WH: The future of lamellar keratoplasty. Curr Opin Ophthalmol 1999;10:253-259.
• Melles GRJ, Lander F, van Dooren BTH, Pels E, Beekhuis WH: Preliminary clinical results of posterior lamellar keratoplasty through a sclerocorneal pocket incision. Ophthalmology 2000;107:1850-1857.
• Melles GRJ: Lamellar Keratoplasty. Moorfields On-line Textbook on Ophthalmology <>

Parallel developments

• Jones DT, Culbertson WW. Endothelial lamellar keratoplasty. Invest Ophthalmol Vis Sci 1998;39(suppl):76, abstract no 342.
• Busin M, Arffa RC, Sebastiani A: Endokeratoplasty as an alternative to penetrating keratoplasty for the surgical treatment of diseased endothelium. Initial results. Ophthalmology 2000;107:2077-2082.

Spin off

• Terry MA, Ousley PJ. Endothelial replacement without surface corneal incisions or sutures: topography of the deep lamellar endothelial keratoplasty procedure. Cornea 2001;20:14-18.
• Jain S, Azar DT. New lamellar keratoplasty techniques: posterior keratoplasty and deep lamellar keratoplasty. Curr Opin Ophthalmol 2001;12:262-268. Review.
• Laibson PR. Current concepts and techniques in corneal transplantation. Curr Opin Ophthalmol 2002;13:220-223. Review.
• Terry MA. Endothelial replacement: the limbal pocket approach. Ophthalmol Clin North Am 2003;16:103-112. Review.
• John T. Use of indocyanine green in deep lamellar endothelial keratoplasty. J Cataract Refract Surg 2003;29:437-443.
• Terry MA, Ousley PJ. Replacing the endothelium without corneal surface incisions or sutures: the first United States clinical series using the deep lamellar endothelial keratoplasty procedure. Ophthalmology 2003;110:755-764; discussion 764.
• Terry MA. A new approach for endothelial transplantation: deep lamellar endothelial keratoplasty. Int Ophthalmol Clin 2003;43:183-193. Review.
• Terry MA, Ousley PJ. In pursuit of emmetropia: spherical equivalent refraction results with deep lamellar endothelial keratoplasty (DLEK). Cornea 2003;22:619-626.
• Terry MA. Deep lamellar endothelial keratoplasty (DLEK): pursuing the ideal goals of endothelial replacement. Eye 2003;17:982-988. Review.
• Terry MA, Ousley PJ. Rapid visual rehabilitation after endothelial transplants with deep lamellar endothelial keratoplasty (DLEK). Cornea 2004;23:143-153.
• Sano Y. Corneal endothelial transplantation: results of a clinical series using deep lamellar endothelial keratoplasty (DLEK). Cornea 2004;23:S55-58.
• Ousley PJ, Terry MA. Stability of vision, topography, and endothelial cell density from 1 year to 2 years after deep lamellar endothelial keratoplasty surgery. Ophthalmology. 2005;112:50-57.
• Amayem AF, Terry MA, Helal MH, Turki WA, El-Sabagh H, El-Gazayerli E, Ousley PJ. Deep lamellar endothelial keratoplasty: surgery in complex cases with severe preoperative visual loss. Cornea 2005;24:587-92.

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I. Vital dyes for intraocular use

II. Advanced surgical techniques for corneal transplantation

III. Alternative surgical settings and logistics

IV. Miscellaneous