[Downloaded free from http://www.ijo.in on Tuesday, October 17, 2017, IP: 149.140.0.94]
Photo Essay Type 2 big bubble deep anterior lamellar keratoplasty‑serial anterior segment optical coherence tomography documentation showing resolution of bubble in the postoperative period Prateek Gujar Key words: Anterior segment OCT, Deep anterior lamellar keratoplasty, type 2 bubble
A 26‑year‑old female underwent big bubble (BB) deep anterior lamellar keratoplasty (DALK) in the left eye for advanced keratoconus. During the procedure, a Type 2 bubble (T2B) with a clear margin and extending to periphery was noticed [Fig. 1]. As manipulating T2B carries a high risk of rupture of Descemet’s membrane (DM), it was left in situ. An anterior chamber paracentesis was done. The procedure was completed by manual layer by layer dissection to get close to DM [Fig. 2]. Donor tissue was secured with interrupted
10‑0 nylon sutures. Postoperative anterior segment optical coherence tomography (AS‑OCT) scans were taken to document the absorption of T2B [Figs. 3‑5]. The bubble got completely absorbed at the end of the first week. At the last follow‑up of 4 months, the patient had an uncorrected visual acuity of 6/36 with a clear graft.
Discussion Perforation of DM during BB DALK remains a common complication necessitating the conversion to penetrating keratoplasty (PKP). The rate of perforation reported ranged from 5% to 19% with conversion to PKP in 0% to 12% of eyes.[1‑3] Types of BB (Type 1 and Type 2) formed during BB DALK can be differentiated based on their clinical appearance.[4] T2B is larger with a thinner wall and usually bursts on minimal
Figure 1: Intraoperative Type 2 bubble (arrow) Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/ijo.IJO_343_17 PMID: *****
Department of Cornea, Sudarshan Netralaya, Bhopal, Madhya Pradesh, India Correspondence to: Dr. Prateek Gujar, Sudarshan Netralaya, Plot No. 1, Old MLA Quarters, Jawahar Chowk, Bhopal ‑ 462 003, Madhya Pradesh, India. E‑mail:
[email protected] Manuscript received: 13.05.17; Revision accepted: 28.08.17
Figure 2: Dissection completed by manual layer by layer method
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact:
[email protected] Cite this article as: Gujar P. Type 2 big bubble deep anterior lamellar keratoplasty-serial anterior segment optical coherence tomography documentation showing resolution of bubble in the postoperative period. Indian J Ophthalmol 2017;65:1017-8.
© 2017 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.ijo.in on Tuesday, October 17, 2017, IP: 149.140.0.94]
1018
Indian Journal of Ophthalmology
Volume 65 Issue 10
Till now no definitive strategy has been recommended for the management of the T2B. Leaving the T2B in situ and completing DALK with manual layer by layer dissection of corneal stroma can be a safe option. The bubble seems to absorb within a week. Figure 3: Postoperative day 1 anterior segment optical coherence tomography image with bubble in situ (arrow)
Conclusion To the best of our knowledge, this is the first reported serial AS‑OCT documentation showing absorption of T2B in the postoperative period. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Figure 4: Postoperative day 3 anterior segment optical coherence tomography image showing partial resolution of Type 2 bubble (arrow)
References 1. Fogla R, Padmanabhan P. Results of deep lamellar keratoplasty using the big‑bubble technique in patients with keratoconus. Am J Ophthalmol 2006;141:254‑9. 2. Fontana L, Parente G, Tassinari G. Clinical outcomes after deep anterior lamellar keratoplasty using the big‑bubble technique in patients with keratoconus. Am J Ophthalmol 2007;143:117‑24.
Figure 5: Postoperative day 7 anterior segment optical coherence tomography image showing complete resolution of Type 2 bubble with clear graft
pressure during cutting the stroma or even during suturing. In one case series, 12 out of the 14 eyes (86%) with T2B during DALK were converted to PKP because of large perforations.[5]
3. Javadi MA, Feizi S, Jamali H, Mirbabaee F. Deep anterior lamellar keratoplasty using the big‑bubble technique in keratoconus. J Ophthalmic Vis Res 2009;4:8‑13. 4. Dua HS, Katamish T, Said DG, Faraj LA. Differentiating type 1 from type 2 big bubbles in deep anterior lamellar keratoplasty. Clin Ophthalmol 2015;9:1155‑7. 5. Goweida MB. Intraoperative review of different bubble types formed during pneumodissection (big‑bubble) deep anterior lamellar keratoplasty. Cornea 2015;34:621‑4.
