An unusual case of acute angle-closure glaucoma following deep anterior lamellar keratoplasty using the “big bubble” technique

Abstract

PurposeTo report the first case of acute angle closure due to a high-pressure Descemet membrane detachment following deep anterior lamellar keratoplasty (DALK) using the “big bubble” technique.ObservationsA 25-year-old man underwent DALK surgery for keratoconus using the “big bubble” technique in which an air bubble is injected in deep stroma to promote dissection of underlying Descemet membrane from stroma. Surgery was uneventful and the patient was discharged home in good conditions. On post-operative day 1, the patient came back with severe periocular pain. Intra-ocular pressure was found to be 38 mmHg. Anterior-segment OCT revealed a “double anterior chamber” created by a high-pressure Descemet detachment that was occluding the pupil and causing secondary acute angle closure glaucoma. The patient was brought back promptly to the operating room where the high-pressure chamber was properly evacuated, allowing Descemet membrane to properly reattach to stroma.Conclusions and importanceInability to recognize stroma from Descemet membrane during the dissection of the “big bubble technique” can result in failure to evacuate the high-pressure Descemet membrane detachment, putting the patient at risk for acute angle closure glaucoma from occlusion of the pupil. Proper dissection of stroma from underlying DM is a challenging and crucial step in the “big bubble” technique. Several methods, such as the injection of small bubbles in the anterior chamber or the use of intra-operative anterior segment OCT could be employed to prevent such a complication.

Secondary angle closure glaucoma due to iatrogenic big bubble formation in manual DALK for stromal degeneration: An unusual presentation

“…We reported the first case of acute angle closure glaucoma due to a big bubble in a rigid cornea. A similar report was published by Jabbour et al [ 2 ], in which DALK was done for a keratoconus patient with compromised corneal stiffness [ 3 ].…”

“…Jabbour et al [ 2 ] managed the complication by removing the donor’s lamellae and continuing dissection until reaching the pre-DM layer, followed by the re-suturing of the graft to the host. We believe this was unnecessary as only 30 microns of the residual stromal bed remained and our action plan was of least intervention with favorable outcomes.…”

Evaluation of Corneal Topography Changes Following Deep Anterior Lamellar Keratoplasty in Patients with Keratoconus

“…DALK surgery does not effect the iridocorneal angle so that outcome is predictable. However, in a case report, acute angle-closure glaucoma following DALK surgery have been reported due to double anterior chamber following DM detachment [15]. Suture techniques or side-port inputs to evacuate air from AC may be changing AC parameters and causing the ACD value to decrease.…”