DALK: Intraoperative pitfalls and how to manage them

Deep anterior lamellar keratoplasty (DALK) has two major advantages over conventional keratoplasty – it completely eliminates failure due to rejection and leaves behind a stronger eye. The steep learning curve associated with the technique deters or frustrates surgeons. This part of the course will highlight the intra-operative pitfalls and how to avoid, anticipate and avoid them using the Big Bubble (BB) technique.

Key steps that will be dealt with are (a) Centration and Trephination. (b) Air injection and identification of the different types of BB (Types 1, 2 and mixed). (c) Lamellar dissection of the anterior stroma and puncturing the bubble without damaging the posterior lamella (Dua's layer + Descemets membrane (DM) or DM alone) (d) Excising the deep residual stroma and extending the dissection if an adequate size bubble is not achieved. (e) Confirmation of type of BB after removing all anterior stroma. (f) Precautions to take to avoid tear or burst (g) How to deal with a tear and aqueous leak (h) What to do if a BB is not achieved. (i) What to do if unsure whether a BB is present or not. (j) Peeling donor DM and suturing the donor graft. All tips will be demonstrated with videos of actual surgical events.