Perforation prevention

Placing a viscoelastic device on the top of the big bubble created during a deep anterior lamellar keratoplasty (DALK) procedure can reduce the risk of Descemet’s membrane perforation during subsequent stages of the operation, according to Yusuf Koçluk MD, of Adana Numune Training and Research Hospital, Adana, Turkey. Speaking at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands, Dr Koçluk noted that perforation of Descemet’s membrane is the most common complication of DALK surgery among surgeons learning the technique. To evaluate the protective effect of viscoelastic on Descemet’s membrane during DALK surgery, he and his associates reviewed the medical records and videos of surgeries of their first 40 DALK patients in whom big-bubble formation could be achieved during the stromal dissection phase of a DALK procedures between January 2014 and July 2015. EXCLUSION CRITERIA The indications for surgery included keratoconus and other corneal stromal dystrophies. The study’s main exclusion criteria were healed corneal hydrops and Descemet’s membrane scarring. The surgeries were performed by the same surgeon using a big-bubble technique. Dr Koçluk and his associates divided the patients into two treatment groups. The first group included 20 eyes in which perforation of stromal bubble was performed in the standard way. The second group included 20 eyes in which they performed the perforation after first applying a viscoelastic device (1.4% sodium hyaluronate) on the stromal wall. Their analysis showed that that perforation of the Descemet’s membrane occurred in only three (15%) of those in eyes in which the viscoelastic was used, compared to 12 (60%) of those in whom it was not. Dr Koçluk noted that their surgical technique 
involved first achieving a big bubble, confirming it by pushing the previously injected small anterior chamber bubble into the periphery. After the anterior part of the stroma was removed they stained a point on the bubble’s stromal surface. STROMAL BUBBLE In the first group of patients, the stained point was carefully punctured using a 20G MVR blade (Alcon). In the second group, the viscoelastic was applied to the stained point just before perforation of the stromal bubble. In both groups, they removed the stroma in quadrants. Dr Koçluk noted that in 75% of cases overall, Descemet’s membrane perforation occurred during the course of stromal wall puncture. However, no Descemet’s membrane perforation occurred during stromal wall puncture in the viscolelastic group. Yusuf Koçluk: kocluk99@gmail.com

Tags: cornea, DALK