Mixed Bubble And Refractory Descemet Membrane Detachment Following Deep Anterior Lamellar Keratoplasty Using A Post-Lasik Donor Cornea

To report a case of refractory Descemet membrane detachment following deep anterior lamellar keratoplasty (DALK), associated with the formation of a mixed big bubble and the use of a donor cornea that had previously undergone LASIK refractive surgery

Consorci Sanitari Integral

A 41-year-old male with keratoconus underwent DALK in his left eye. An apparently type I bubble was achieved. After complete stromal removal, a mixed bubble was identified, consisting of a type I bubble and a type II bubble in the inferonasal quadrant.

At the end of the procedure, an air bubble was left in the anterior chamber (AC) to promote coaptation of both bubbles. Cycloplegia was prescribed because the patient was phakic and had no inferior iridotomy. Supine positioning was recommended.

Postoperatively, the patient presented corneal edema. Anterior segment OCT revealed detachment and splitting of Descemet’s membrane (DM) in the inferonasal quadrant. 

A second intervention was required, guided with intraoperative OCT, a new air bubble was injected into the AC, and interface fluid was drained. During this procedure, a previously undetected LASIK flap in the donor cornea was identified.

Postoperatively, DM successfully reattached in the area corresponding to the type I bubble; however, localized stromal edema persisted in the region associated with the type II bubble. One month later, the type II bubble resolved completely and DM was fully adherent, but a residual area of corneal haze remained, requiring repeated DALK.

During retransplantation,  donor cornea that had undergone previous LASIK was removed and replaced with a new anterior lamellar graft without complications. No Descemet detachment was observed postoperatively, and the patient showed favorable clinical evolution.

Identifying a type III mixed bubble is essential, as it predisposes to postoperative Descemet membrane detachment (DMD) and may be challenging to recognize intraoperatively.

In such cases, leaving an air bubble in the anterior chamber alone may not be sufficient to prevent DMD. An additional intentional puncture of the pre-Descemet layer may be required to release the type II air pocket within the mixed bubble and reduce the risk of postoperative detachment.

In this case, the use of a donor cornea that has previously undergone refractive surgery with LASIK may have compromised stromal integrity, leading to a fragile host–donor interface and potentially perpetuating DMD and a final hazy cornea.