Salvaging Deep Anterior Lamellar Keratoplasty with Microbubble Incision Technique in Failed “Big Bubble” Cases: An Update Study

Purpose To report the achievement rate of bare Descemet membrane (DM) dissection with the help of microbubble incision technique in eyes with failed big bubble formation and to investigate the mechanism of the microbubble rescue technique through ex vivo imaging of human cadaver corneas. Methods This retrospective clinical study included 80 eyes of 80 patients that underwent deep anterior lamellar keratoplasty (DALK). In 22/80 (27.5%) cases, big bubble dissection failed. After puncturing the microbubbles, viscodissection helped to achieve separation of DM from the remaining stroma. In addition, an ex vivo study with human cadaver cornea specimens, gross photography, and anterior segment optical coherence tomography imaging was accomplished ex vivo to explore the mechanism of this method. Results Microbubble dissection technique led to successful DALK in 19 of 22 cases of failed big bubble. Microperforation occurred in 3 eyes. Deep anterior lamellar keratoplasty was completed without any complications in 2 out of the 3 eyes with microperforation. In 1 eye, conversion to penetrating keratoplasty was required. Microbubble-guided viscodissection achieved 95.4% (21/22) success in exposing bare DM in failed big-bubble cases of DALK. Anterior segment optical coherence tomography imaging results of cadaver eyes showed where these microbubbles were concentrated and their related size. Conclusions Microbubble-guided DALK should be considered an effective rescue technique in achieving bare DM in eyes with failed big bubble. Our ex vivo experiment illustrated the possible alterations in cornea anatomy during this technique.