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First Author: J.Gandhewar UK
Co Author(s): N. Toumia I. Choudhary V. Savant
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We report a case of post-operative migration of air from the cornea resulting in acute pupil block glaucoma and impending central retinal artery occlusion following uneventful deep anterior lamellar keratoplasty.
Royal Derby Hospital Medical Centre. Surgical/clinical setting
A 26-year old male with keratoconus, underwent uneventful deep anterior lamellar keratoplasty (DALK) with big bubble technique in the right eye. One hour later, he complained of eye pain and loss of vision. Visual acuity of the operated eye was no perception of light, with an IOP of 45 mmHg. The cornea was relatively clear and the anterior chamber was deep centrally. The peripheral iris was apposed to the cornea peripheral to the corneal graft junction, all around 360 degrees. A large central air bubble in the interface space between the corneal graft and the host corneal tissue was suspected to cause pupil block glaucoma and the appearance of the peripheral iris. The pupil started to show early relative afferent pupillary defect. Immediate anterior chamber paracentesis with aspiration of air was successfully performed. Few second later, the anterior chamber regained normal anatomy, the intraocular pressure dropped to normal and his vision significantly improved. One month post-operatively, patient maintains best corrected visual acuity of 6/9 in the operated eye with a healthy optic disc and retina.
Whilst performing the big bubble technique, air inadvertently entered the peripheral cornea up to the limbus in the infero-temporal quadrant. Post-operatively, there is assumed to have been migration of air from the peripheral cornea into the graft host interface space. This resulted in pupil block glaucoma with possible impending central retinal artery occlusion resulting in no perception of light. This was promptly treated with anterior chamber paracentesis. According to our knowledge, this is the first reported case of post-operative migration of air resulting in acute loss of vision due to raised intra-ocular pressure.