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Outcomes of deep anterior lamellar keratoplasty following successful and failed ‘big bubble’
  1. Uday K Bhatt1,
  2. Usama Fares2,
  3. Imran Rahman1,3,
  4. Dalia G Said1,
  5. Senthil V Maharajan1,
  6. Harminder S Dua1,2
  1. 1Department of Ophthalmology, Queens Medical Centre, Nottingham, UK
  2. 2Department of Ophthalmology, University of Nottingham, Nottingham, UK
  3. 3Department of Ophthalmology, Blackpool Victoria Hospital, Blackpool, UK
  1. Correspondence to Professor Harminder S Dua, Chair and Professor of Ophthalmology, University of Nottingham, Eye ENT Centre, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK; harminder.dua{at}


Aim The most popular technique for deep anterior lamellar keratoplasty (DALK) is the ‘big bubble’ (BB) technique wherein air is injected in the cornea to create a bubble that separates Descemet's membrane (DM) from the stroma. An attempt to create a BB often results in the cornea being filled with numerous small bubbles without the formation of a BB. Manual dissection is then required to complete the procedure. The aim of the study is to compare these two groups, successful BB versus failed bubble (FB) dissection to determine whether the clinical outcomes were different.

Methods In this retrospective comparative study, 46 patients out of 52 who underwent DALK for various corneal stromal diseases such as keratoconus, stromal dystrophy or corneal scarring (caused by different conditions) were included in the analysis. BB was achieved in 25 patients and in the remaining 21 patients a BB separation of the DM was not possible necessitating manual lamellar dissection of stroma to get as close to the DM as possible.

Results The authors compared best-corrected visual acuity, contrast sensitivity, astigmatism, interface densitometry and Scheimpflug pachymetry in the two groups. Postoperative corneal thickness was higher in the ‘small bubbles’ group (mean 628.9 vs 564.1 μm; p<0.0005), but there was no significant difference in best-corrected visual acuity, astigmatism, contrast sensitivity and densitometry between the groups.

Conclusions In DALK, manual lamellar dissection is a reasonable alternative when BB separation of the DM is not achieved.

  • Corneal graft
  • lamellar keratoplasty
  • surgical outcomes
  • cornea
  • imaging
  • ocular surface
  • optics and refraction
  • conjunctiva
  • degeneration
  • treatment surgery
  • inflammation
  • medical education
  • wound healing
  • eye (tissue) banking

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  • Competing interests None.

  • Ethics approval This study was done as a part of clinical audit and permission of the institutional audit board was obtained to carry out this retrospective audit.

  • Provenance and peer review Not commissioned; externally peer reviewed.