Intraoperative perforation of Descemet's membrane during “big bubble” deep anterior lamellar keratoplasty

Abstract

To analyze the reasons for intraoperative perforation of Descemet's membrane during deep anterior lamellar keratoplasty (DALK) during the learning curve. DALK was attempted in 35 eyes of 33 patients with pathologies involving the corneal stroma and sparing of Descemet's membrane (DM), including patients with keratoconus, corneal stromal dystrophies and healed keratitis. The surgical plan included complete removal of the corneal stroma using the "big bubble" technique for exposing Descemet's membrane followed by grafting of a full-thickness corneal stromal lenticule. DALK was converted into full-thickness penetrating keratoplasty in eight eyes (23%), which included patients with keratoconus (n = 6), macular corneal dystrophy (n = 1) and healed keratitis (n = 1). Main reasons for conversion were perforation of the DM due to excessive air injection (four eyes) and improper surgical maneuvers (three eyes). One case had deposits on Descemet's membrane upon exposure of the DM. A successful penetrating keratoplasty could be performed in all eight eyes. During the learning curve, excessive air injection and inappropriate surgical maneuvers may complicate a DALK resulting in conversion to penetrating keratoplasty.

Big Bubble Deep Anterior Lamellar Keratoplasty for Management of Deep Fungal Keratitis

“…Intraoperative perforation of DM is one of the most common complications during DALK surgery, with a rate of 9% to 23% [27, 28]. In cases with FK, the stroma usually has edema, which allows more adequate intraoperative stromal dissection compared to patients with stromal scarring [29].…”

Red Reflex-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty

“…6 The most critical step in achieving successful big-bubble formation remains the insertion of the needle or cannula into the stroma: a too superficial approach usually results in diffuse corneal emphysema without bubble formation, whereas too deep insertion can lead to Descemet membrane (DM) perforation, requiring conversion to PK. 7 In recent years, several techniques have been suggested to judge the dissection depth, including the use of air reflection, triamcinolone on the endothelium, slit lamp attached to a microscope, intraoperative anterior segment optical coherence tomography (AS-OCT), or a femtosecond laser. [8][9][10] We describe another method to judge the dissection depth using lines seen in the red reflex of the microscope light source as a reference to guide the insertion of a blunt probe down to a pre-Descemetic plane.…”

Spontaneous resolution of double anterior chamber with perforation of Descemet′s membrane in deep anterior lamellar keratoplasty

“…[4–7] Some surgeons abandon DALK and convert to PKP whenever a perforation occurs, a strategy not justified as studies show it leads to poorer visual results. [6] After perforation, the rate of immediate conversion to PKP in the recent reports ranges from 0% to 100%. [56] Double AC can occur in patients with inadvertent perforation due to influx of aqueous into the potential space between the donor and the recipient.…”

“…[6] After perforation, the rate of immediate conversion to PKP in the recent reports ranges from 0% to 100%. [56] Double AC can occur in patients with inadvertent perforation due to influx of aqueous into the potential space between the donor and the recipient. This usually resolves with a tight air fill of the anterior chamber.…”