Successful Deep Anterior Lamellar Keratoplasty Following Intraoperative Macro-Rupture

To report  surgical management of intraoperative macro-rupture during Deep Anterior Lamellar Keratoplasty (DALK)

Apollo Hospitals, Hyderabad, INDIA

A 28 year old male with advanced keratoconus, & intolerance to contact lens wear was advised to undergo DALK for improvement in vision. His preoperative best spectacle corredted visual acuity (BSCVA) was < 20/200, steep keratometry was 81 diopters and minimum corneal thickness was 261 microns. Intraoperatively, stromal air injection was performed after an initial 8.5mm partial thickness corneal trephination. A type 1 big bubble (BB) was successfuly initiated, however as it was being enlarged to the trephination  margin, a large macro rupture occurred, extending from one edge of trephination margin to the other. Manual stromal dissection was initiated from the trephination margin, to enter into the plane of type 1 BB. Residual stroma was  excised followed by placement of same size donor cornea devoid of DM whcih was secured  with interrupted sutures. Inferior surgical PI was performed followed by placement of air bubble in AC. Reverse Sinskey was now used to appose the torn posterior edges of the break, followed by a complete air fill. Post operatively he recovered well wtih relatively clear cornea. At one year follow up his BSCVA had improved to 20/30 with normal corneal curvature and thickness. 

Macro-rupture occuring during DALK surgery does not always require a conversion to full thickness penetrating keratoplasty. Air or gas tamponade can be used for a successful visual outcome in such scenarios.