To compare the 5-year outcomes of 9mm deep anterior lamellar keratoplasty (DALK) for keratoconus against those converted to mushroom keratoplasty (MK).
Retrospective cohort study METHODS: .
Ospedali Privati “Villa Igea”, Department of Ophthalmology, Forlì, Italy PATIENT OR STUDY POPULATION: The medical records of all attempted DALKs (416 eyes) for the indication of keratoconus performed between January 2012 and January 2018 were evaluated, 68 (16.4%) of which were converted to MK and analysed as a separate cohort. The mean follow-up time was 33.8±15.1 months.
9 mm DALK and MK (9 mm anterior lamella with 6 mm posterior lamella) MAIN OUTCOME: Measures: Best corrected visual acuity (BCVA), refractive astigmatism, endothelial cell loss (ECL) at 5 years.
Average BCVA at 5 years was 0.06±0.07 in DALK group and 0.09±0.15 in the MK group (p=0.88). Refractive astigmatism following suture removal (all visits later than 12 months) was slightly less in the DALK cohort (5-year DALK=2.16D±1.40, MK 3.02D±0.89, p=0.04, mean difference 0.86D (95%CI 0.71-1.01)). ECL was significantly higher in the MK group than in the DALK group at all follow up intervals (5-year DALK = 19.36%±21.47, MK 56.61%± 15.82, p<0.001). Total all-cause graft failure rate at 5 years was 0.58% for DALK (2/348 cases) and 5.88% for (4/68 cases).
Excellent 5-year visual and clinical outcomes associated with a two-piece mushroom keratoplasty in cases converted from intended DALK mandate large diameter DALK (9mm) as the optimal surgical approach to keratoconus.

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