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Modified Miyake–Apple Camera: Illustration of Deep Anterior Lamellar Keratoplasty Pearls Learned From Simultaneous Anterior and Posterior Corneal Imaging

Moloney, Gregory MBBS, FRANZCO; Tan, Johnson C. H. MBBS, FRCSEd (Ophth), FAMS; Yeung, Sonia N. MD, PhD, FRCSC; Gupta, Aanchal MBBS, FRANZCO; White, Valerie A. MD, MHSc, FRCPC; McCarthy, J. Martin MD, FRCSC; Holland, Simon P. MD, FRCSC

doi: 10.1097/ICO.0000000000000142
Basic Investigation

Purpose: The aim of this study was to demonstrate surgical pearls in big-bubble deep anterior lamellar keratoplasty using a modified Miyake–Apple camera system and to correlate these findings with histology.

Methods: This was a wet laboratory-based pilot study. Cadaveric human corneal tissue consented for research and not suitable for transplantation was fixed to a glass slide and assembled into the modified Miyake–Apple camera system. Dissections were performed and recorded. Selected specimens were submitted for light microscopy.

Results: Key points illustrated by video analysis included the entry of air into the artificial anterior chamber through the trabecular meshwork without Descemet membrane perforation, the contrast of this event with frank perforation, the potential of viscoelastic injection as a salvage maneuver, and the modes of air passage during the procedure. Histological correlation confirmed the air passage through the trabecular meshwork and demonstrated the appearance of pneumatized corneal stroma in the setting of a failed big-bubble and corneal “white-out.”

Conclusions: We present the video analysis that correlated with the histology of air behavior during big-bubble deep anterior lamellar keratoplasty. The chief points illustrated include signs associated with air entry into the eye in the presence and absence of Descemet perforation.

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*Division of Cornea and External Disease, Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada;

Discipline of Ophthalmology, Sydney Eye Hospital Campus, University of Sydney, Sydney, Australia;

National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore;

§South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia; and

Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.

Reprints: Gregory Moloney, Sydney Cornea Clinic, Level 12, 187 Macquarie St, Sydney, New South Wales 2000, Australia (e-mail:

S. P. Holland has received research support from Alcon Laboratories Inc and received travel support from Allergan and Bausch & Lomb. The other authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received November 09, 2013

Accepted March 25, 2014

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.