Anterior Lamellar Keratoplasty Over Penetrating Keratoplasty for Optical, Therapeutic, and Tectonic Indications: A Case Series MARCUS ANG, JODHBIR S. MEHTA, ANSHU ARUNDHATI, AND DONALD T. H. TAN ● PURPOSE: To report a consecutive case series of pa- tients who underwent anterior lamellar keratoplasty (ALK) over a preexisting penetrating keratoplasty (PK). ● DESIGN: Retrospective, interventional case series. ● METHODS: Eight patients (8 eyes) were identified from the Singapore Corneal Transplant Study database, in a single institution (Singapore National Eye Center) from patients who underwent ALK performed over a PK. Main outcome measures were final visual acuity (VA), graft failure (ALK, PK or both), successful restoration of tectonic integrity in tectonic indications, and eradication of infection in therapeutic cases. ● RESULTS: The indications for surgery were therapeutic in 3 patients, optical in 3 patients, and tectonic in 2 patients. Postoperatively the best-corrected visual acuity (BCVA) improved in 5 eyes and remained unchanged in 3 eyes. Mean VA improved significantly after ALK; the mean preoperative BCVA was 1.52  0.25 and the mean postoperative BCVA was 0.87  0.26 (P  .032). Three of the 8 eyes post-lamellar keratoplasty (LK) managed to attain a BCVA equal to post-PK BCVA. Two patients had suture micro-perforations while 1 patient required a repeat ALK for recurrence of infec- tion. ● CONCLUSION: ALK may be a considered as a viable alternative to a repeat PK for a variety of optical, therapeutic, and tectonic indications. (Am J Ophthal- mol 2009;147:697–702. © 2009 by Elsevier Inc. All rights reserved.) B ULLOUS KERATOPATHY REMAINS THE LEADING IN- dication for penetrating keratoplasty (PK) in the industrialized world. 1,2 However, repeat PK is be- coming a leading indication for corneal grafting. 2 The survival graft rates at 5 and 10 years drop significantly in repeat PKs as compared with the initial PKs, 2,3 and visual outcome in repeat PKs is often poorer than first time grafts. 3,4 In a select group of patients, where the pathology requiring a repeat graft is limited to the stroma, an anterior lamellar keratoplasty (ALK) over the previous PK may be considered as an alternative to a repeat PK. This would provide the advantages of visual rehabilitation and re- moval of the stromal pathology without exposing the patient to the increased risk of allogenic rejection and failure from a repeat PK. 5 The aim of this article is to report on a series of patients who underwent an ALK over a PK, for a variety of optical, therapeutic, and tectonic indications requiring anterior stromal replacement of the previous penetrating graft. We report on surgical techniques, visual acuity (VA) out- comes, and complications in this group of patients. METHODS THE MEDICAL RECORDS OF ALL PATIENTS WHO UNDER- went ALK after an initial PK were identified from the Singapore Corneal Transplant Study (SCTS) Database of the Singapore National Eye Center (SNEC) between January 1, 1991 and May 31, 2008 and reviewed retrospec- tively. The SCTS database prospectively collects data on all grafts performed by all corneal surgeons at SNEC, including preoperative clinical data, surgical details, and donor tissue data, as well as postoperative follow-up data on an indefinite basis. 2 Data retrieved from the medical records included pa- tient demographics, ophthalmic history, details of surgery, and clinical outcome. Specific data that was collected for the current study were: 1) clinical presentation, including preoperative and postoperative Snellen VA with refrac- tion; 2) indications and surgical details of initial PK; 3) time interval between the initial PK and ALK; 4) indica- tion for secondary surgical intervention; 5) surgical details of subsequent ALK; 6) duration of post-ALK follow-up; 7) final outcome; 8) surgical complications; and 9) postoper- ative medications. Outcome measures were final VA, graft failure (ALK, PK, or both), successful restoration of tectonic integrity in tectonic indications, and eradication of infection in ther- apeutic cases. Graft failure was defined as an irreversible loss of central graft clarity from any cause, irrespective of the level of VA. Best-corrected visual acuity (BCVA) with Accepted for publication Oct 1, 2008. From the Singapore National Eye Centre (M.A., J.S.M., A.A., D.T.H.T.), the Singapore Eye Research Institute (J.S.M., A.A., D.T.H.T.), and the Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore (D.T.H.T.), Singapore. Inquiries to Donald T. H. Tan, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751; e-mail: snecdt@pacific.net.sg © 2009 BY ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/09/$36.00 697 doi:10.1016/j.ajo.2008.10.002