BLOG: Grip and rip keratoplasty: More elegant than it sounds

ByJohn A. Hovanesian, MD, FACS

There’s an old joke about a rookie executive from a record company playing a sample tape from a new band to his more seasoned colleague. Hearing the music, the veteran executive grimaces and asks his young colleague, “Why do you think we should sign this new band?” The young colleague replies, “Their music is better than it sounds.”

While it’s hard to contemplate how music can be better than it sounds, an anterior lamellar keratoplasty technique described in a great YouTube video by Mark Vital of Houston Eye Associates has impressed me as being far more worthy of attention than its name might suggest. The name “grip and rip” does not exactly connote surgical elegance or precision, but this technique clearly has both.

Grip and rip keratoplasty is performed for anterior stromal dystrophy or ectasia with a healthy posterior corneal surface. The recipient cornea is trephined partial thickness to about 250 µm. At this depth, the surgeon performs about 1 mm of lamellar dissection with a sharp blade around the superior 180° of the trephine cut. Then, the partial-thickness corneal button is removed by forcefully gripping it in the center of this dissection with robust, toothed Green forceps. Counter tension is provided by 0.12 or 0.3 forceps on the peripheral host rim. The diseased cornea is pulled inferiorly with enough force to pull apart the corneal lamellae, which naturally finds a deep dissection plane, sometimes baring Descemet’s membrane. Next, a donor cornea, which has been oversized by 0.25 mm to 0.5 mm, is punched from donor tissue that has been precut by a microkeratome to a depth of about 350 µm. This is sewn in place in a traditional ALK technique.

The diseased central cornea is pulled free from deep stromal attachments with forceps in this procedure performed by Patricia Sierra, MD, of Sacramento Eye Consultants on a volunteer trip in Tegucigalpa, Honduras.

Photo provided by John A. Hovanesian.

Having done this procedure as well as the more traditional “big bubble” technique of ALK, I feel the grip and rip technique is much easier to learn and get consistent, reproducible results with very little risk for endothelial rupture or conversion to penetrating keratoplasty — the bane of big bubble. While grip and rip does not guarantee dissection down to Descemet’s, there is probably little harm in leaving 50 µm to 150 µm of residual deep stroma. The deep dissection is much more smooth than in the sharp dissection used with other techniques because the stromal dissection follows the natural collagen fiber’s organization when the tissues are pulled apart. This technique is not for the faint of heart. The cornea requires more pulling than most of us would immediately be comfortable with — creating a “rip” in the cornea is not something we are accustomed to, but it is the essence of this technique.

Maybe this technique should be renamed “collagen-guided deep anterior lamellar keratoplasty,” or maybe a marketing company could come up with a better name. Either way, I believe it is a technique that should be familiar to every corneal surgeon, and it surely deserves a place in our treatment of anterior corneal disease.

Disclosure: Hovanesian reports no relevant financial disclosures.