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Big Bubble Technique in Anterior Lamellar Keratoplasty

Panda, Anita MD, NAMS, FICS, MRC(Ophth)a; Pangtey, Mayank S. MDa; Sony, Parul MDa; Khokhar, Sudershan MDa

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Journal of Cataract & Refractive Surgery: December 2002 - Volume 28 - Issue 12 - p 2067
doi: 10.1016/S0886-3350(02)01904-1
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We admire the effort of Anwar and Teichmann in their recent paper on a new technique to bare Descemet's membrane in anterior lamellar keratoplasty.1 The technique facilitates separation of the corneal layers and will no doubt enable smoother and easier lamellar separation in places in which corneal surgeons do not have access to sophisticated tools such as microkeratomes and lasers. Although lamellar keratoplasty was introduced to the field of corneal surgery 150 years ago, it has not been used by everyone for various reasons. Besides its time-consuming nature, suboptimal visual outcome from interface opacity is blamed for its decreasing popularity. As irregular lamellar separation is a major factors in interface opacification, efforts have been made to achieve a smooth and regular recipient bed. This is greatly facilitated by lamellar separation.

In 1974, Anwar tried to modify the technique of dissection. Further studies appeared subsequently. These include air dissection by Archila3 and Price,4 viscodissection by Manche and coauthors5 and Melles and coauthors,6 and hydrodissection by Amayem and Anwar.7 In 2000, we compared air, viscoelastic, and hydrodissection for the same and found that the lamellar hydration technique offered better results in surgical speed without untoward effects.8 Being pioneers in the field of lamellar dissection, we could compare the hydrotechnique with the “big bubble” technique.

To conclude, we believe the technique has a good future as far as complications are concerned but it appears to be a time-consuming proposition. We therefore would like to know about its indications, the time required to complete the procedure, and the visual outcome in a randomized prospective study.

Finally, we would like to express our sincere gratitude to the authors for bringing this neglected but important issue to the notice of ophthalmologists and suggesting a new technique.

Anita Panda MD, NAMS, FICS, MRC(Ophth)

Mayank S. Pangtey MD

Parul Sony MD

Sudershan Khokhar MD

aNew Delhi, India


1. Anwar M, Teichmann KD. Big bubble technique to bare Descement's membrane in anterior lamellar keratoplasty. J Cataract Refract Surg 2002; 28:398-403
2. Anwar M. Technique in lamellar keratoplasty. Trans Ophthalmol Soc UK 1974; 94:163-171
    3. Archila EA. Deep lamellar keratoplasty dissection of the host tissue with intrastromal air injection. Cornea 1984; 3:217-218
    4. Price FW Jr. Air lamellar keratoplasty. Refract Corneal Surg 1989; 5:240-243
    5. Manche EE, Holland GN, Maloney RK. Deep lamellar keratoplasty using viscoelastic dissection. Arch Ophthalmol 1999; 117:1561-1565
    6. Melles GRJ, Remeijer L, Geerards AJM, Beekhuis WH. A quick surgical technique for deep anterior lamellar keratoplasty using viscodissection. Cornea 2000; 19:427-432
    7. Amayem AF, Anwar M. Fluid lamellar keratoplasty in keratoconus. Ophthalmology 2000; 107:76-79
    8. Panda A, Singh R. Intralamellar dissection techniques in lamellar keratoplasty. Cornea 2000; 19:22-25
    © 2002 by Lippincott Williams & Wilkins, Inc.