DALK

[Ali Akay]

Anne,
I know DALK is the "in" thing now and the prospect of life-long freedom from rejection is very attractive, but I am not really too sure about the whole thing. I don't know what the latest statistics are, but I'd think risk of rejection with penetrating grafts is pretty small, and usually managed well.I think most would agree that visual rehabilitation after DALK is slower than PKP and it can take a long time for the interface haze to clear. I know an experienced surgeon who doesnt do DALKs but gets very good results with PKPs with low astigmatism.As a clinician I find it reassuring to see a nice clear cornea after PKP rather than waiting and hoping for interface haze to clear after DALK. Like everything else, I guess it's a matter of weighing up pros and cons and deciding for yourself. Unfortunately there's an element of "fashion" in medicine and at present DALK is fashionable and surgeons sticking to full thickness grafts could be regarded as behind the times or "old fashioned" whether this is justified or not. I dont know if there is pressure on surgeons to perform DALK as a lot of patients are well informed nowadays, and perhaps some of the poor results are due partly to inexperience.

[GarethB]

Ali,

Good to see you posting again, you are quite correct in thinking rejection after PK is pretty small.

The idea of DALK is that the risk is evel smaller and so far it would appear to be the case. Being the scientist taht I am, I am still open minded as to which is the best, would like to see more data before I make a firm decision.

[Ali Akay]

Hi Gareth
We all agree that rejection risk after DALK is less than PKP. The question is whether we are getting too fixated on that to forget the visual outcome! Obviously far too early to have enough data to make a sensible comparison of long term safety, graft clarity, post-op astigmatism etc. I'd make an analogy with refractive surgery. Virtually all corneal surgeons carry out LASIK,LASEK etc. My guess is that even those who may have reservations about long term safety etc do it as they probably feel obliged to do it! Apart from the financial rewards they'd want to demonstrate their expertise in the latest technology. Similarly if you asked a corneal surgeon if he did DALK perhaps he'd want to be able to say yes even if he wasnt 100% convinced that it is the best option. Dont get me wrong I am not necessarily "anti-DALK" as I've seen some very good results, but it does require a lot of skill, and the slow improvement in vision can be frustrating for the patient.

Having said all this I believe DALK is here to stay and PKP will gradually be phased out, and the problems with DALK will gradually be ironed out. I just wanted to remind people that full thickness grafts have been with us for a long time, and it is a tried and tested method.It probably is not a bad thing if surgeons carry on refining both techniques until we have enough data to decide which is better! Rather than asking your surgeon whether you should have DALK or PKP, perhaps a more appropriate question is how much experience he has in the two techniques and whether he is more confident in getting a good outcome with one or the other!

[Anne B]

My biggest concern i have is, that my DALK opp will turn into a full thickness graft .
The reason for this is i have Atopic Keratoconjuctivitis and i believe that alone puts me at a higher risk for rejection.

Please correct me if i'm talking cobblers

Anne

[jayuk]

Anne

Whilst there is evidence of higher than average graft failure with AKC; I beleive if its spotted early enough it can be controlled and regressed....but again...the best person to speak with on this issue is the consultants.....as it kinda ups the ante on him performing the DALK well

HTH

J

[John Smith]

All interesting stuff (and welcome back Ali!).

For me, once the idea of a second graft was raised, I immediately asked about DALK because of the lower rejection rates (I have had nine rejection episodes with my left eye and wanted to minimise the risk for the right).

My then consultant is not skilled in performing DALK grafts, and she suggested I saw a different consultant.

One of the things I was therefore keen to ask the new consultant was the incidence of his DALK grafts being converted to PK. I was pleasantly surprised by the answer as I understood his answer to be about half what I'd previously read.

Anne, I know your consultant knows mine (as he mentioned his name in his conference presentation) and it may be worth comparing this incidence. I'll PM you with my consultant's details if you want them.

For the record, my DALK graft was performed using freeze-dried donor material (which, I'm assured, reduces the rejection rate from very low to zero) and only 5% of his grafts go on to become PK.

Your consultant is eminent in his field, and I'm sure that he'll be able to reassure you. Make sure you mention your AKC worries, too; and listen to his advice.

At the end of the day, the decision on how to proceed is yours - and we can only make this informed choice by asking questions.

Best of luck, and let us know how you get on.

[Sajeev]

Hi Anna,

John Dart certainly knows of Mini-ark, because I told him about it in a letter to him some three years ago, when people was just dismissing it out of hand.

I received a letter back and it said that they tried RK (Please remember it is RK not mini-ark) for KC before in the UK, with out much success. So the thought of cutting in to a weak cornea is not a big no no... its done after a graft to correct astigmitisum for example.

Anyway mini-ark is a modified version of RK which Dr Lombadri uses, which gives him success, and uses it to either give back contact lenses wear (when contact lens wear was impossible due the cone), by getting the cornea back to a contact lens wearable level in profile. OR to free people from contact lens wear altogether!!! so either they are back wearing glasses or need no more correction.

Level one and two cones can be corrected with very good results uncorrected and SELECTED cases of level three cones.

To create back the correct corneal profile, it may need to be done in two stages, it must be remembered, as thats the best way to do it depending on the nature of the cone.

It is not the cookie cutter mentality of just replacing the cornea like in the throw away society we live in... its more skillful by looking in to the problem ...in much more detail.

Dr Lombadri will say "yes" and "no" to what he can do and what he can not do for a patient.

He has already said sometime ago on the German forum that it can not be "made a rule" to treat level three keratoconus all of the time (as patients was pestering him when he said "no" to them)... only selected cases of level three KC can be treated with mini-ark... So he may actually say "No" mini-ark will not work for you Anne... but will make a suggection of what may be the best option for you Anne...

Implantable lenses is another option... it all depends on the condition of your KC. There is a Dr in the UK that will do this for KC after taking a look at your case (again he may say "No"). And also there is a Dr in the UK who would try incisional surgery for KC and done in a way that a PK can be done if need be (not mini-ark though).

Certainly find out all you can Anne... it can only help...

Good Luck

[Anne B]

Hi All

Please don't get me wrong, i have every faith in John Dart doing a great job.
But i feel the need to find out more about mini ARK or aleast ask some question before it is to late.

My consultant is well aware of my AKC amd doesn't feel it a big problem, I am the one that is scared, I just don't want any regrets.
He has arranged for me to see him 2 weeks before the opp and he will start me on a course of steroids.

I cannot get a appointment before my graft so i am going to E mail him with my Questions.

Anne

[Hari Navarro]

Ali's comments on the 'fashion' aspect of medical treatment ring very true for me.
One of the knee jerk reactions of those in the know who are asked about mini ARK is to compare it to the results of Rk...
Rk very much enjoyed its peak some years ago when it was the 'in thing' for astigmatic correction. All that was needed was a scalpel and a patient list to begin work... obviously the results were varied. But these same results are quoted to debunk any resurgence of the surgeon based incisional treatments.

We hear time and time again that RK is an 'old school' technique that has been pushed aside by lazer technology... but is this entirely true?
I personally believe that it is surgical skill that wins out. The ability to see each case as individual and to adapt the procedure accordingly.

DALK may become flavour of the month but mini ARK has been on select menus for going on 20 years.

Why then if it is not at all possible (bearing in mind that mini ARK does not contridict a possible future graft) is it not at least attempted pre PK? It may be that the patient is to far advanced to benefit from ARK but why is it not considered in the screening process?

I think again the answer is skill... are there legions of surgeons expert in incisional surgery out there that that are availble to treat every potential ARK patient even if it was proved a valid procedure?
Not to invalidate the many highly skilled doctors that we have but I think medicine, as with many other industries, is losing many of its true craftsmen.

Hari

[Hari Navarro]

Good luck with your appointment Anne... I too would be very interested in hearing Mr. Darts view on ARK mini-ARK.
Let us know how you get along

Hari
Ps: It would also be interesting to get a general consensus on exactly what the current view is of operating on already thin corneal tissue. It has always been stated as a contridiction but I am reading more and more of surgery being used in the case of KC.