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Microbubble Incision as a New Rescue Technique for Big-Bubble Deep Anterior Lamellar Keratoplasty With Failed Bubble Formation

Riss, Stephan MD; Heindl, Ludwig M. MD; Bachmann, Björn O. MD; Kruse, Friedrich E. MD, PhD; Cursiefen, Claus MD, PhD

doi: 10.1097/ICO.0b013e31824a226f
Clinical Science

Purpose: To describe a new surgical technique allowing dissection down to Descemet membrane in big-bubble deep anterior lamellar keratoplasty (DALK) with failed big-bubble formation (the “microbubble incision technique”).

Methods: This is an interventional case series of 10 consecutive patients with keratoconus undergoing intended big-bubble DALK with failure to establish a normal big bubble. In all patients, repeated air injections into the stroma were performed, leaving a whitish colored stroma. Lamellar dissection as far down as possible was then performed within this white tissue. As soon as the anterior chamber was visible, a large remaining intrastromal air bubble was incised with a sharp 15-degree knife introduced perpendicular to the tissue to open up this predescemetic bubble. If deeper air bubbles were still visible, this approach was repeated. Using a blunt spatula, this new layer was then prepared and viscodissection performed.

Results: Using this novel approach, in 9 of the 10 patients, it was possible to dissect down to Descemet membrane. Macroperforation made conversion to penetrating keratoplasty necessary in 1 patient. Microperforations not necessitating conversion occurred in 2 patients. All 9 patients with “rescued” DALK had an uneventful postoperative course and had a mean visual acuity of 20/63 ± 20/125 (range, 20/500–20/50) and a mean endothelial cell count of 1672 ± 163 cells per square millimeter (range, 1493–1867 cells/mm2) at 3 months.

Conclusions: Microbubble incision is a new rescue technique for big-bubble DALK patients without bubble formation allowing for a safer dissection down to Descemet membrane.

*Department of Ophthalmology, University of Erlangen-Nürnberg, Erlangen, Germany

Department of Ophthalmology, University of Cologne, Cologne, Germany.

Reprints: Claus Cursiefen, Department of Ophthalmology, University of Cologne, Joseph-Stelzmann-Strasse 9, D-50924 Köln, Germany (e-mail:

Supported by the German Research Foundation Grant (SFB 643, B10).

The authors state that they have no financial or conflicts of interest to disclose.

Received September 16, 2011

Accepted January 7, 2012

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