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

Abstract

Deep anterior lamellar keratoplasty (DALK) using Dr. Anwar's big bubble technique was performed for a patient with granular dystrophy. Intraoperatively, a perforation of the Descemet's membrane (DM) was noted inferonasally. Though the surgery was completed, the donor graft appeared to have an intact endothelium, which was inadvertently left behind by the surgeon. Intraoperatively, there was a perforation of inferonasal DM and surgery was completed by inadvertently placing a donor with an intact endothelium. Postoperatively the patient presented with a complete DM detachment and a resultant double anterior chamber (DAC). In spite of two attempts at an air tamponade on the first and fifth post operative days, the DAC still persisted. Surprisingly, during the 6th week follow up visit, there was a complete resolution of the DAC as well as total recovery of vision. This interesting case clearly exemplifies that, in spite of failed attempts at air tamponade, a DM detachment and a DAC due to DM perforation following a DALK procedure can resolve spontaneously with good visual outcome.

Deep anterior lamellar keratoplasty: A surgeon's guide

“… 89 Failed attempt at air tamponade for a DM detachment and a double anterior chamber due to DM perforation following a DALK procedure can resolve spontaneously with good visual outcome after several weeks. 90 …”

Intraoperative management of macroperforations of Descemet’s membrane in deep anterior lamellar keratoplasty

“…Macroperforations, however, are readily seen because of an immediate loss of anterior chamber stability, and often require surgical conversion to PK [ 14 ]. There have been several reports on the successful completion of pdDALK in the presence of a perforation of DM [ 5 , 8 , 9 , 11 ]. To date, no safe and reproducible strategy has been offered to the corneal surgeon on how to approach such cases.…”

“…Perforation of Descemet’s membrane (DM) during trephination, deep stromal injection of air, or dissection are known complications of attempted big-bubble, Descemet-baring DALK (dDALK) [ 4 ]. While microperforation of DM commonly allows for the completion of pre-descemetic DALK (pdDALK) by lamellar dissection (LD) after decompression of the anterior chamber, macroperforations measuring more than 1 mm require conversion to PK [ 5 , 6 ]. In the presence of a corneal perforation the big-bubble technique is not possible and LD is the only surgical option [ 7 ].…”

A case of Descemet’s membrane detachments and tears during phacoemulsification

“… 12 DMD has also been reported in Descemet membrane endothelial keratoplasty and deep anterior lamellar keratoplasty. 13 , 14 Several mechanisms have been implicated in the etiology of DMD, such as a shallow anterior chamber, 1 use of blunt microkeratomes, 15 shelved and/or anteriorly placed incisions, 16 , 17 engagement of the DM during intraocular lens implantation, 18 the inadvertent injection of saline into the space between the deep stroma and the DM. 12 …”