Kaufman² and Werblin³ proposed epikeratoplasty as a simple procedure for the correction of aphakia in 1980. In epikeratoplasty, a donor corneal lenticule is frozen, shaped with a cryolathe, and sutured to the anterior corneal surface to provide the appropriate optical correction (myopic, plano, or hyperopic). Alternatively, the button may be lyophilized and stored in a vacuum container for later use. The advantage of epikeratoplasty over earlier procedures was that the lenticules could be prepared in a centralized location by a company (e.g., Allergan Medical Optics [AMO], Cryo-Optics) dedicated to lenticule production. This meant that the surgeon needed to master only the surgical procedure and not the use of the cryolathe.

During the 1980s, several multicenter national studies were sponsored by AMO to assess the efficacy of epikeratoplasty for several conditions: pediatric aphakia, adult aphakia, myopia, and keratoconus.^4,5,6,7 The procedure was promoted as a fairly simple surgery that could be performed by most general ophthalmologists as an alternative to aphakic spectacles in the adult or for pediatric aphakia, or in lieu of penetrating keratoplasty for keratoconus. It was also promoted as a good technique for performing lamellar corneal patch grafts in cases of corneal thinning or perforation. Because the lenticules are not an economically viable product, they are no longer commercially available from AMO.

The surgeon provided two pieces of information to the central tissue processing center to facilitate preparation of the donor lenticule: the patient’s spherical equivalent of refraction at the corneal plane and the average central keratometry readings. The tissue was custom lathed for each patient and delivered to the operating surgeon. The tissue lens was removed from the vacuum container and rehydrated in balanced salt solution with antibiotic (gentamicin). The patient’s optical center was located and marked with a needle or Sinsky hook. Centration was extremely important, especially in the cases of myopic epikeratoplasty. A donut of central corneal epithelium was then removed by a combination of mechanical and chemical debridement. The central 2 to 3 mm of corneal epithelium containing the centering mark were left intact temporarily. A Hessburg-Barron vacuum trephine was centered on the optical axis, and a 0.25-mm partial-thickness trephination was performed (Fig. 1). An annular keratectomy was performed, in cases of keratoconus, to improve adherence of the epigraft to the host corneal stroma. The vertical trephination was undermined approximately 1 mm peripherally with a Suarez spreader or comparable instrument to allow the edge of the graft to seat nicely in the keratectomy. The residual central host epithelium was then removed mechanically and the graft bed was sometimes treated with absolute alcohol or 4% cocaine to remove any residual epithelial cells. The cornea was irrigated copiously with balanced salt solution, and the rehydrated epikeratoplasty lenticule was sutured into position with 16 to 24 interrupted 10-0 nylon sutures. Careful attention was paid to making equal bites on the donor and recipient sides. The ideal suture tension should be equal in every direction. The knots were trimmed and buried just beneath the surface of the recipient to make suture removal easier. The graft edges were then tucked into the peripheral keratectomy, and subconjunctival antibiotic and/or steroids were administered.