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  Vincenzo Scorcia, Valentina De Luca, Andrea Lucisano, Adriano Carnevali, Giovanna Carnovale Scalzo, Cristina Bovone and Massimo Busin
  Published on: 17 January 2019
• Tuning Of The Literature Related To The Airviscobubble (AVB) DALK Technique
  Vincenzo Sarnicola, Enrica Sarnicola and Caterina Sarnicola
  Published on: 17 January 2019

• Published on: 17 January 2019

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  • Vincenzo Scorcia, Associate Professor Department of Ophthalmology, University of “Magna Graecia”, Catanzaro, Italy
  • Other Contributors:
    • Valentina De Luca, Ophthalmologist
    • Andrea Lucisano, Ophthalmologist
    • Adriano Carnevali, Ophthalmologist
    • Giovanna Carnovale Scalzo, Ophthalmologist
    • Cristina Bovone, Ophthalmologist
    • Massimo Busin, Full Professor

  We thank Dr. Sarnicola and family for their interest in our work and at the same time we apologize for not mentioning their preliminary results published in 2010; in this regard, some issues need be clarified.
  We used an acronym to shorten the text and facilitate the readers of our article by eliminating this way long descriptive wording of the procedure. This did not imply by any means an attempt at modifying the terminology of surgical techniques, which is usually a task of the ophthalmological community. In fact, a particular acronym becomes a standard only when it is cited as such by numerous papers in the literature. This is not seeming the case, for the acronym “AVB”, that has never been used after its initial introduction by Sarnicola et al., thus failing to achieve the purpose aimed at.
  In addition, we had a reason to introduce a new acronym because of a substantial difference in the surgical technique: in fact, instead of creating a new corneal tunnel into the emphysematous tissue, we inject ophthalmic viscoelastic device (OVD) in the same track created for pneumatic dissection, thus increasing surgical reproducibility and safety.
  The lack of previous data we indicated (“…little data are available on the success rate…type of cleavage obtained, visual results and complications of this approach”) was simply related to the new concept of performing the injection of the OVD in the same corneal path where the air had failed.
  In our series visual...

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  We thank Dr. Sarnicola and family for their interest in our work and at the same time we apologize for not mentioning their preliminary results published in 2010; in this regard, some issues need be clarified.
  We used an acronym to shorten the text and facilitate the readers of our article by eliminating this way long descriptive wording of the procedure. This did not imply by any means an attempt at modifying the terminology of surgical techniques, which is usually a task of the ophthalmological community. In fact, a particular acronym becomes a standard only when it is cited as such by numerous papers in the literature. This is not seeming the case, for the acronym “AVB”, that has never been used after its initial introduction by Sarnicola et al., thus failing to achieve the purpose aimed at.
  In addition, we had a reason to introduce a new acronym because of a substantial difference in the surgical technique: in fact, instead of creating a new corneal tunnel into the emphysematous tissue, we inject ophthalmic viscoelastic device (OVD) in the same track created for pneumatic dissection, thus increasing surgical reproducibility and safety.
  The lack of previous data we indicated (“…little data are available on the success rate…type of cleavage obtained, visual results and complications of this approach”) was simply related to the new concept of performing the injection of the OVD in the same corneal path where the air had failed.
  In our series visual acuity was significantly better after big bubble-DALK than after viscobubble-DALK in the first postoperative months, suggesting a transient negative effect of the OVD; this is an original result never described in any of the papers cited by the Sarnicola et al. in addition, they classified as dDALK all those procedures with a successful pneumatic dissection, whereas we now know that most of big bubbles created with air injection are actually pre-descemetic. This has been demonstrated by several authors after the initial observation by Dua.1 This mistake due to the lack of knowledge of the true anatomy of the floor is combined with the procedural error of putting together all cases with a successful bubble creation, without distinction between those obtained with air injection and those obtained with OVD injection. Our original results show a significant difference in postoperative vision between these two subgroups and represents the main original contribution of the paper. Instead, the methodology used by the Sarnicola group leads to a completely false analysis of the results because it is based to the erroneous assumption that all successful bubbles are descemetic.

  References:
  1. Dua HS, Faraj LA, Said DG, et al. Human corneal anatomy redefined: a novel pre-
  Descemet’s layer (Dua’s layer). Ophthalmology 2013;120:1778–85.

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  Conflict of Interest:
  None declared.

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• Published on: 17 January 2019

  Tuning Of The Literature Related To The Airviscobubble (AVB) DALK Technique

  • Vincenzo Sarnicola, Ophthalmologist Clinica degli Occhi Sarnicola, Grosseto, Italy
  • Other Contributors:
    • Enrica Sarnicola, Ophthalmologist
    • Caterina Sarnicola, Resident in Ophthalmology

  Tuning Of The Literature Related To The Airviscobubble (AVB) DALK Technique
  Corresponding author:
  Vincenzo Sarnicola
  Address: Clinica degli Occhi Sarnicola,
  Via Mazzini no. 62, Grosseto 58100, Italy.
  Fax: +39-0564-413023
  Tel: +39-3201158500
  e-mail address: v.sarnicola@hotmail.it or sarnicolavincenzo@gmail.com

  Authors:
  Vincenzo Sarnicola, MD1
  v.sarnicola@hotmail.it

  Enrica Sarnicola, MD1-3
  e.sarnicola@hotmail.it

  Caterina Sarnicola, MD 4
  c.sarnicola@hotmail.it

  Affiliation:
  1 Clinica degli Occhi Sarnicola, Grosseto, Italy
  2 Ospedale Oftalmico di Torino, Struttura Complessa Oculistica 2, Turin, Italy
  3 Ospedale San Giovanni Bosco, Struttura Complessa Oculistica 2, Turin, Italy
  4 Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy;

  Competing interests: None.

  Keywords: DALK; airviscobubble; AVB; dDALK; descemetic DALK.

  Word Count: 303

   
  To the Editor:

  We read with interest the article published by Scorcia et al.[1] It is encouraging to see others, such as Scorcia et al, embracing the use of ophthalmic viscoelastic device (OVD) injection as a second bubble a...

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  Tuning Of The Literature Related To The Airviscobubble (AVB) DALK Technique
  Corresponding author:
  Vincenzo Sarnicola
  Address: Clinica degli Occhi Sarnicola,
  Via Mazzini no. 62, Grosseto 58100, Italy.
  Fax: +39-0564-413023
  Tel: +39-3201158500
  e-mail address: v.sarnicola@hotmail.it or sarnicolavincenzo@gmail.com

  Authors:
  Vincenzo Sarnicola, MD1
  v.sarnicola@hotmail.it

  Enrica Sarnicola, MD1-3
  e.sarnicola@hotmail.it

  Caterina Sarnicola, MD 4
  c.sarnicola@hotmail.it

  Affiliation:
  1 Clinica degli Occhi Sarnicola, Grosseto, Italy
  2 Ospedale Oftalmico di Torino, Struttura Complessa Oculistica 2, Turin, Italy
  3 Ospedale San Giovanni Bosco, Struttura Complessa Oculistica 2, Turin, Italy
  4 Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy;

  Competing interests: None.

  Keywords: DALK; airviscobubble; AVB; dDALK; descemetic DALK.

  Word Count: 303

   
  To the Editor:

  We read with interest the article published by Scorcia et al.[1] It is encouraging to see others, such as Scorcia et al, embracing the use of ophthalmic viscoelastic device (OVD) injection as a second bubble attempt after a failed air big bubble (BB) with air. However, it looks unreasonable to use new acronym (VB-DALK).[1] We would like to highlight that the orginal technique was first described by Sarnicola et al in 2010 and named airviscobubble (indicated with the acronym “AVB”).[2] Scorcia et al probably did not notice this paper in literature, citing only a later study by Muftuoglu et al from 2013.[1-3] Consistency of terms that are well-established in literature should be maintained. Attempting to rename both the name (viscobubble DALK instead of airviscobubble) and the acronym (VB-DALK instead of AVB) of a recognized technique without specific reasons does not serve any purpose as it is confusing for to readers and problematic for the comparison of future studies.
  The Authors also stated in the introduction of their paper that “…little data are available on the success rate, type of cleavage obtained, visual results and complications of this approach”.[1] A more complete review of the literature would demonstrate the inaccuracy of this statement.[4-9] Several studies have reported the efficacy of AVB as a rescue bubble technique, showing a 15% increase of descemetic DALK in 507 eyes, the advantages of using a cannula for the OVD injection, the usefulness of the technique even in cases of herpetic corneal scar, and the importance of performing a paracentesis before the AVB formation.[4-9]
  Despite the manuscript is very well written and pleasant to read, we would like to draw attention to another small inaccuracy. The consideration statement reported in the 6th paragraph of the discussion section (“The loss of pressure … trephination size.”) is missing the appropriate reference.[1,3]

  REFERENCES:

  1. Scorcia V, DE Luca V, Lucisano A, et al. Br J Ophthalmol 2018;102:1288–1292. doi:10.1136/bjophthalmol-2017-311419
  2. Sarnicola V, Toro P, Gentile D, et al: Descemetic DALK and predescemetic DALK: outcomes in 236 cases of keratoconus. Cornea 2010;29:53-9.
  3. Muftuoglu O, Toro P, Hogan RN, et al. Sarnicola air-visco bubble technique in deep anterior lamellar keratoplasty. Cornea 2013;32:527-32.
  4. Sarnicola V, Toro P. Blunt cannula for descemetic deep anterior lamellar keratoplasty. Cornea 2010;30:859-8.
  5. Sarnicola V, Toro P. Deep anterior lamellar keratoplasty. In herpes simplex corneal opacities. Cornea 2011;29:60-4.
  6. Sarnicola V, Toro P, Sarnicola C, et al. Long-term graft survival in deep anterior lamellar keratoplasty. Cornea. 2012;31:621-6.
  7. Sarnicola E, Sarnicola C, Sarnicola V. Deep anterior lamellar keratoplasty: surgical technique, indications, clinical results and complications. In: Guell JL, ed. Cornea ESASO Course Series. Basel, Switzerland: Karger; 2015:81-101.
  8. Sarnicola V, Sarnicola E, Sarnicola C. Recovery techniques in DALK, Chapter 120
In: Mannis M, Holland E Cornea 4th edition 2016. Editor: Elsevier - Health Sciences Division.
  9. Sarnicola E, Sarnicola C, Sabatino F, et al. Cannula DALK versus Needle DALK for Keratoconus. Cornea 2016;35:1508-11.

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  Conflict of Interest:
  None declared.

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