Using a "small bubble technique" to aid in success in Anwar's "big bubble technique" of deep lamellar keratoplasty with complete baring of Descemet's membrane.

AIM: To describe the "small bubble" technique to immediately determine the success of attaining complete Descemet's membrane (DM) separation from corneal stroma via Anwar's "big bubble" technique of deep anterior lamellar keratoplasty (DALK).

METHODS

A partial trephination was followed by a lamellar dissection of the anterior stroma. Deep stromal air injection was then attempted to achieve the big bubble to help separate the stroma from the DM. To confirm that a big bubble has been achieved a small air bubble is injected into the anterior chamber (AC) via a limbal paracentesis. If the small bubble is then seen at the corneal periphery, it confirms that the big bubble separation of DM has been successfully accomplished, as the convexity of the bubble will protrude posteriorly forcing the small AC bubble to the periphery. If the small AC bubble is not seen in the corneal periphery, this means that it is present centrally, beneath the opaque corneal stroma, and therefore the big bubble has not been achieved. We used the small bubble technique to confirm the presence of the big bubble intraoperatively in a keratoconus patient.

RESULTS

Complete stromal removal with baring of the descemet's membrane was achieved and postoperatively the patient achieved best corrected vision of 6/6.

CONCLUSION

The small bubble technique helps in confirming the separation of DM from the deep stroma, which is important in achieving the goal of total stromal replacement. To view the full report and accompanying video please go to: http://bjo.bmj.com/cgi/content/full/92/3/422/DC1 All videos from the BJO video report collection are available from: http://bjo.bmj.com/video/collection.dtl.