Corneal collagen cross-linking (CXL) is the current gold standard to arrest the progression of keratoconus but its efficacy remains less predictable in thinner and steeper corneas. For such scenarios, a simple approach of transplanting Bowman layer and anterior stroma called a 'Bowman-stromal Inlay' (BSI) in Keratoconic patients as an intervention to cease progression of ectasia and increase the overall thickness of cornea is a new option.
S𝘁𝗲𝗽𝘀 𝗼𝗳 S𝘂𝗿𝗴𝗲𝗿𝘆 𝗜𝗻𝗰𝗹𝘂𝗱𝗲:
1. A Intrastromal pocket is created in patient's Cornea using femtosecond laser
2. A Inlay consisting of the Bowman's layer and anterior stroma is harvested from Donor Cornea using femtosecond laser
3. The Implantation of inlay in recipient's intrastromal pocket using IOL injector
S𝘁𝗲𝗽 𝗜 – 𝗜𝗻𝗹𝗮𝘆 𝗽𝗿𝗲𝗽𝗮𝗿𝗮𝘁𝗶𝗼𝗻
- The Donor Corneal tissue is mounted on an artificial anterior chamber
- An alcohol assisted epithelial debridement is done to prevent epithelial ingrowth later
- The Limbus is marked to ensure centration of graft
- The Lamellar keratoplasty setting is used to harvest Anterior lamellar graft - Bowman’s layer + Anterior stroma
- Graft docking and centration is performed
- A Donor Cornea of desired thickness is cut from the top
- 360 edges of the lenticule are raised with LASIK flap lifter
S𝘁𝗲𝗽 𝗜𝗜 – 𝗥𝗲𝗰𝗶𝗽𝗶𝗲𝗻𝘁 𝗣𝗿𝗲𝗽𝗮𝗿𝗮𝘁𝗶𝗼𝗻 (𝗜𝗻𝘁𝗿𝗮𝘀𝘁𝗿𝗼𝗺𝗮𝗹 𝗽𝗼𝗰𝗸𝗲𝘁)
- A Femtosecond laser is used with modified settings of LASIK flap software with minimal energy for side cut to create an intrastromal corneal pocket in the recipient’s cornea
S𝘁𝗲𝗽 𝗜𝗜𝗜 – 𝗜𝗻𝘁𝗿𝗮𝘀𝘁𝗿𝗼𝗺𝗮𝗹 I𝗻𝗷𝗲𝗰𝘁𝗶𝗼𝗻 𝗼𝗳 I𝗻𝗹𝗮𝘆
- The patient and the Inlay are both brought to the main operating room
- The incision is made with a guarded knife
- A Tunnel is opened up with appropriate dissectors
- A Stromal pocket is opened up for smooth insertion of Inlay
- The Centre of the cornea is marked to ensure that the Inlay is placed in the centre of visual axis
- The Inlay is loaded into the IOL cartridge with Bowman's layer side up
- The tip of the injector is engaged in the canal
- The Inlay is injected into the stromal pocket
- The Inlay is unfolded with the help of 26G cannula and surface taps
- The Inlay is centred around the pupil by massaging the surface of the Cornea
- A bandage contact lens is placed at the end of the surgery
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