Triple Anterior Chamber Following Combined Deep Anterior Lamellar Keratoplasty With Dense Cataract Phacoemulsification

To report a case of phacoemulsification of a dense brunescent cataract below Dua's layer during deep anterior lamellar keratoplasty for a dense deep central corneal scar. This was followed by dealing with a rare complication of having triple anterior chamber early after surgery. 

The surgery was operated at Ibn Al Haitham teaching eye hospital in Baghdad, Iraq. Constellation phaco machine from Alcon along with Zeiss Lumera I microscope were used with a low specular corneal graft prepared with vacuum based trepine and punch from Barron.

An elderly male, single eyed, presented with severe worsening of vision over the last few months with exotropia. He has long history of corneal scar. Imaging confirms deep stromal location. His visual acuity was hand movement and ultrasound exam showed flat retina. A plan for corneal graft along with cataract surgery and lens implantation was discussed and a consent was obtained. The surgery started with 350Mm trephination followed by 2 unsuccessful big bubble formation. Manual dissection was performed reaching bare Dua's layer (DL). An intumescent cataract was seen. After coating the DL with Methyl Cellulose, 27g needle decompression followed by spiral rehexis was done. Phacoemulsification by divide and conquer and lens implantation into the bag was performed. Corneal graft was prepared then sutured to the bed with 10/0 nylon. On day 1, patient presented with 3 anterior chambers, confirmed by imaging. The first was presumed due to unwashed viscoelastics, while a small peripheral Decemet's membrane detachment (DMD) was obeserved also. SF6 gas injection with peripheral iridectomy along with paracentral small venting incisions and interface washout were done. One week after this, double anterior chamber was still evident from a small DMD for which a second rebubbling saved the situation. Ending up with a clear graft and a single anterior chamber.

1. Dua's layer is strong enough to withstand phacoemulsification even for brunescent cataract.

2. Thourough washout of both recipient and the graft inner face is required during lamellar keratoplasty.

3. Complications are not uncommon while dealing with complex surgeries. The surgeon need to be focused in every second intraoperatively besides to being ready to deal with complications while maintaining a clear target to reach.