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PHOTO ESSAY
Year : 2017  |  Volume : 65  |  Issue : 10  |  Page : 1017-1018

Type 2 big bubble deep anterior lamellar keratoplasty-serial anterior segment optical coherence tomography documentation showing resolution of bubble in the postoperative period


Department of Cornea, Sudarshan Netralaya, Bhopal, Madhya Pradesh, India

Date of Submission13-May-2017
Date of Acceptance28-Aug-2017
Date of Web Publication17-Oct-2017

Correspondence Address:
Prateek Gujar
Sudarshan Netralaya, Plot No. 1, Old MLA Quarters, Jawahar Chowk, Bhopal - 462 003, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_343_17

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  Abstract 


Keywords: Anterior segment OCT, Deep anterior lamellar keratoplasty, type 2 bubble


How to cite this article:
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

How to cite this URL:
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 [serial online] 2017 [cited 2020 Feb 28];65:1017-8. Available from: http://www.ijo.in/text.asp?2017/65/10/1017/216747

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 [Figure 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 [Figure 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 [Figure 3],[Figure 4],[Figure 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.
Figure 1: Intraoperative Type 2 bubble (arrow)

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Figure 2: Dissection completed by manual layer by layer method

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Figure 3: Postoperative day 1 anterior segment optical coherence tomography image with bubble in situ (arrow)

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Figure 4: Postoperative day 3 anterior segment optical coherence tomography image showing partial resolution of Type 2 bubble (arrow)

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Figure 5: Postoperative day 7 anterior segment optical coherence tomography image showing complete resolution of Type 2 bubble with clear graft

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  Discussion Top


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],[2],[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 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] 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.


  Conclusion Top


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.

 
  References Top

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.  Back to cited text no. 1
[PUBMED]    
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.  Back to cited text no. 2
[PUBMED]    
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.  Back to cited text no. 3
[PUBMED]    
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.  Back to cited text no. 4
[PUBMED]    
5.
Goweida MB. Intraoperative review of different bubble types formed during pneumodissection (big-bubble) deep anterior lamellar keratoplasty. Cornea 2015;34:621-4.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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