Clinical Report: iOCT-Guided Femto-DALK in 42 Eyes

Overview

This retrospective, single-center case series evaluated femtosecond laser-assisted deep anterior lamellar keratoplasty (Femto-DALK) using an iOCT-guided pre-Descemet tunnel in 42 eyes treated from January 2020 through December 2023. The supplied article text describes the study design and surgical approach but does not provide the series’ numerical outcomes, so rates of big-bubble formation, perforation, conversion, and postoperative results cannot be reported here.

Background

DALK is used for stromal corneal disease when the endothelium is healthy, preserving the patient’s Descemet membrane and endothelium. Compared with penetrating keratoplasty, the source describes potential advantages including avoidance of endothelial rejection and open-sky surgery, as well as lower risks of some postoperative complications. The manual creation of a pre-Descemet tunnel for air injection is technically challenging, and reported big-bubble formation rates vary with surgeon experience and corneal pathology. Femtosecond laser cuts and iOCT guidance have been proposed to improve the precision of tunnel placement, but earlier encouraging reports were often based on experimental tissue or small case series.

Data Highlights

Key Findings

• The study included all patients undergoing Femto-DALK with the Ziemer LDV Z8 at the University of Düsseldorf from January 2020 through December 2023.
• All procedures were performed by a single surgeon under general anesthesia.
• The laser was used to create an OCT-guided intrastromal pre-Descemet tunnel intended to facilitate pneumatic dissection.
• Preoperative OCT-derived pachymetry informed the planned lamellar dissection depth; the supplied text states that the plane was planned 200 microns anterior to the thin, but the sentence is incomplete.
• The investigators retrieved intraoperative measures including big-bubble formation, Descemet membrane perforation, conversion to penetrating keratoplasty, and surgical duration, as well as postoperative outcomes; their results are not present in the supplied excerpt.
• The source describes manual tunnel creation as technically challenging and cites previously reported big-bubble formation rates of 36.4%–87%, with approximately 60% reported in a 326-eye multisurgeon study.

Clinical Implications

The supplied material supports describing iOCT-guided femtosecond tunnel creation as the technique evaluated, not as a proven improvement in clinical outcomes. Because the excerpt omits the case-series results, it does not support conclusions about procedural success, complication rates, conversion risk, or postoperative effectiveness.

Conclusion

This 42-eye series addresses a technically demanding step in DALK by evaluating an iOCT-guided, laser-created pre-Descemet tunnel. The available source text provides the methods but not the outcome data needed to assess clinical performance.

Related Resources & Content

1. BMC Ophthalmology, 2026 — Success of femtosecond laser-assisted deep anterior lamellar keratoplasty (Femto-DALK): a clinical case series of 42 eyes using an intraoperative optical coherence tomography (iOCT)-guided laser-generated pre-descemet tunnel
2. Corneal Physician, 2021 — Customizing the Cut
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7. Success of femtosecond laser-assisted deep anterior lamellar keratoplasty (Femto-DALK): a clinical case series of 42 eyes using an iOCT-guided laser-generated pre-descemet tunnel
8. Customizing the Cut
9. Anterior segment imaging
10. Evidence-Based Clinical Practice Guideline for Diagnosis, Treatment, and Follow-Up of Keratoconus Patients - PMC
11. ESCRS:The Second Global Consensus on Keratoconus
12. Paired-Eye Analysis of Deep Anterior Lamellar Keratoplasty Versus Mushroom Penetrating Keratoplasty Over 5 Years - PubMed
13. Long-term follow up (≥ 10 years) of penetrating keratoplasty versus deep anterior lamellar keratoplasty for keratoconus - PubMed
14. Penetrating keratoplasty versus deep anteriror lamellar keratoplasty for macular corneal dystrophy: A meta-analysis.
15. Clinical outcomes and complications of deep anterior lamellar keratoplasty in ectatic and non-ectatic corneal diseases - ScienceDirect
16. A randomized controlled trial comparing femtosecond-enabled deep anterior lamellar keratoplasty and standard deep anterior lamellar keratoplasty (FEDS Study) - PMC
17. Success of femtosecond laser-assisted deep anterior lamellar keratoplasty (Femto-DALK): a clinical case series of 42 eyes using an intraoperative optical coherence tomography (iOCT)-guided laser-generated pre-descemet tunnel | BMC Ophthalmology | Springer Nature Link
18. One-Step Intraoperative Optical Coherence Tomography Guided Tunnel, Mushroom Femtosecond Laser Big Bubble Deep Anterior Lamellar Keratoplasty