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Surgical Technique |

Small-Bubble Deep Anterior Lamellar Keratoplasty Technique

Vincenzo Scorcia, MD1; Jacqueline Beltz, MD, FRANZCO2; Massimo Busin, MD1,2,3
[+] Author Affiliations
1Department of Ophthalmology, University of Magna Graecia, Catanzaro, Italy
2Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
3Department of Ophthalmology, Ospedale Privato Villa Igea, Forlì, Italy
JAMA Ophthalmol. 2014;132(11):1369-1371. doi:10.1001/jamaophthalmol.2014.2756.
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Stromal disease (ectasia, opacities, scars, or melting) that occurs after penetrating keratoplasty (PK) can variously affect visual outcome.1,2 To date, even in the presence of healthy endothelium, this type of complication has been treated with subsequent PK.3 Instead, the selective replacement of the diseased stroma by means of deep anterior lamellar keratoplasty (DALK) using pneumatic dissection (big bubble) has not been attempted, mainly because of the extreme likelihood of breaking the descemetic scar at the junction between the donor and host cornea. We describe a new surgical technique (small-bubble DALK) that uses pneumatic dissection to bare Descemet membrane (DM) only in a central optical zone and predescemetic manual dissection to remove the surrounding peripheral stroma.

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Figure 1.
Surgical Steps of Small-Bubble Deep Anterior Lamellar Keratoplasty

A, Recurrent ectasia in an eye with a decentered penetrating keratoplasty (arrowheads). B, Trephination, 8.5 mm in diameter, up to 70% to 80% of peripheral corneal thickness. C, Air injection into deep stroma by means of a blunt 27-gauge cannula to achieve a bubble 5 to 6 mm in diameter. D, After removal of the superficial stroma, baring of the Descemet membrane with blunt corneal scissors. E, Manual predescemetic dissection and removal of the residual peripheral deep stroma. F, Fixation of donor tissue with 2 running 10-0 nylon sutures.

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Figure 2.
Results of Small-Bubble Deep Anterior Lamellar Keratoplasty Performed in Eyes With Recurrent Ectasia After Penetrating Keratoplasty

A, Preoperative slitlamp appearance. B, Anterior segment optical coherence tomography (AS-OCT). C, Corneal topography of an eye with recurrence of ectasia 6 years after penetrating keratoplasty. D, Three months after small-bubble deep anterior lamellar keratoplasty, the cornea is perfectly clear with no sign of ectasia. E, Area of peripheral manual dissection as seen with AS-OCT (arrowhead). F, Fifteen months after surgery, corneal topography reveals the presence of low-degree regular astigmatism.

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