Bowman layer onlay grafting as a minimally invasive treatment for the most challenging cases in keratoconus

Lydia van der Star, Indrė Vasiliauskaitė, Silke Oellerich, Esther A Groeneveld-van Beek, Mohamed Ghaly, Achraf Laouani, Keamela Vasanthananthan, Korine van Dijk, Isabel Dapena, Gerrit R J Melles, Viridiana Kocaba

Research output: Contribution to journalArticlepeer-review

Abstract

Purpose: To analyze the clinical outcomes after Bowman layer (BL) onlay grafting for the treatment of progressive, advanced keratoconus. Design: Prospective, interventional case series. Methods: Twenty-one eyes underwent BL onlay grafting. After removing the epithelium, a single or double BL graft was “stretched” onto the corneal surface, allowed to dry-in, and a soft bandage lens was placed until the graft was re-epithelialized. Best spectacle- and/or best contact lens–corrected visual acuity (BSCVA/BCLVA), corneal tomography, and postoperative complication rates were analyzed for the total group and 2 subgroups (group 1: preoperative maximum keratometry [Kmax] <69 diopters [D; n = 7); group 2: preoperative Kmax ≥69 D [n = 14]). Follow-up ranged from 6 to 36 months (mean 21 ± 11 months). Results: All 21 surgeries were uneventful. Overall, Kmax changed from 76 ± 12 D preoperatively to 72 ± 9 D at 6 to 36 months postoperatively (P = .015). Kmax decreased by 6 D in group 2 (P = .002) but did not change in group 1. Average BSCVA remained stable for group 1 and improved from preoperatively 0.8 ± 0.4 to 0.4 ± 0.2 logarithm of the minimum angle of resolution postoperatively in group 2 (P = .032); BCLVA remained stable (P > .05). Within the first postoperative weeks, 2 eyes required BL graft repositioning after inadvertent bandage lens removal and 4 eyes underwent BL retransplantation for incomplete re-epithelialization. One eye underwent BL regrafting 12 months postoperatively after traumatic corneal erosion. All eyes showed a completely re-epithelialized graft at the last available follow-up. Conclusions: BL onlay grafting is a completely extraocular, minimally invasive surgical technique, providing up to −6 D of corneal flattening in eyes with advanced progressive keratoconus, allowing for continued (scleral) contact lens wear and therefore preserving the BCLVA.

Original languageEnglish
Pages (from-to)54-65
Number of pages12
JournalAmerican Journal of Ophthalmology
Volume261
DOIs
Publication statusPublished - May 2024

Bibliographical note

Funding Information:
All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. Funding/Support: Underlying research reported in this study was supported by unrestricted grants from Landelijke Stichting voor Blinden en Slechtzienden, Rotterdamse Stichting Blindenbelangen, and Oogfonds that contributed through UitZicht. The funding organizations had no role in the design or conduct of this research. Financial Disclosures: NIIOS-USA has a patent application pending related to this manuscript. G.R.J.M. is a consultant for SurgiCube International. All authors attest that they meet the current ICMJE criteria for authorship.

Funding Information:
All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. Funding/Support: Underlying research reported in this study was supported by unrestricted grants from Landelijke Stichting voor Blinden en Slechtzienden, Rotterdamse Stichting Blindenbelangen, and Oogfonds that contributed through UitZicht. The funding organizations had no role in the design or conduct of this research. Financial Disclosures: NIIOS-USA has a patent application pending related to this manuscript. G.R.J.M. is a consultant for SurgiCube International. All authors attest that they meet the current ICMJE criteria for authorship.

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© 2023

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