Spontaneous Resolution Of An Intradescemetic Air Bubble Following Deep Anterior Lamellar Keratoplasty For Keratoconus

Deep anterior lamellar keratoplasty (DALK) has become a preferred surgical option for keratoconus, with pneumatic dissection techniques such as the “big-bubble” method being commonly used. Such techniques have enhanced stromal-Descemet membrane (DM) separation but have also introduced potential complications, including descemet membrane detachment, micro-perforation, and double anterior chamber formation. This case report describes a rare postoperative finding of a localized intradescemetic air bubble following otherwise uneventful DALK using the big-bubble technique.

Ophthalmology clinic at Hull Royal Infirmiry hospital, involving the cornea team. Observational case report of postoperative findings following deep anterior lamellar keratoplasty performed for advanced keratoconus.

A patient with advanced keratoconus in the right eye underwent uneventful DALK using the big-bubble (deep stromal air injection) technique. On postoperative day 2, slit-lamp examination revealed a clearly defined, localized air bubble trapped within the intradescemetic space. There was no evidence of DM tear, double anterior chamber, or fluid cleft. The anterior chamber was well formed, graft apposition was satisfactory, and intraocular pressure (IOP) remained within normal limits.

Anterior segment optical coherence tomography (AS-OCT) confirmed the presence of a localized intradescemetic air pocket without associated DM detachment or interface fluid.

Given the lack of concerning features, a conservative observational approach was adopted rather than immediate intervention and the patient was reviewed 48 hours later. By postoperative day 4, the air bubble had completely resolved on slit-lamp examination. The graft remained clear, the interface smooth, and no adverse sequelae such as DM detachment or graft oedema were observed. Visual recovery continued as expected.

The clinical features, supported by AS-OCT findings were consistent with an intradescemetic air bubble, likely resulting from lamellar separation within the DM during big-bubble formation or a subtle microperforation allowing air entry. The localized appearance, stable anterior chamber, and spontaneous resorption supported this diagnosis and justified non-interventional management.

Intradescemetic air trapping is a rare but benign postoperative finding following DALK that may mimic more serious complications such as Descemet membrane detachment or interface separation. Careful clinical assessment is essential to distinguish these entities. In the absence of graft compromise, anterior chamber instability, or pressure elevation, conservative observation is appropriate. Awareness of this presentation can prevent unnecessary surgical intervention and supports the safety of expectant management when clinical parameters remain stable.