Descemet's membrane perforation during deep anterior lamellar keratoplasty: Prognosis

PURPOSE: To evaluate the functional and endothelial prognosis after Descemet's membrane perforation during deep anterior lamellar keratoplasty (DALK). SETTING: Private practice, Siena, Italy. METHODS: A retrospective study evaluated a series of 35 eyes that had DALK using the big-bubble technique. RESULTS: Intraoperative perforation occurred in 8 eyes (23%), in 5 eyes during manual deep dissection and in 1 eye each during trephination, as the air needle was introduced in the stroma, and as the big bubble was punctured. In all 8 eyes, DALK could be completed. In 1 case, pupillary block was caused by air left in the anterior chamber, resulting in permanent mydriasis and anterior subcapsular opacity. In another case, a double anterior chamber persisted and penetrating keratoplasty was later required. In the other 6 cases, the postoperative course was uneventful. The mean postoperative best spectacle-corrected visual acuity was 0.8 +/- 0.13 (SD) and the mean postoperative refractive astigmatism, 2.09 +/- 0.98 diopters. The mean endothelial cell loss, evaluated in 7 eyes, was 12% +/- 11% at 1 month (P<.05) and 14% +/- 12% at 12 months. The mean cell loss was 25% +/- 2.7% in eyes in which intraoperative reformation of the anterior chamber with air was required and 6% +/- 7.5% in eyes in which it was not (P< .05). CONCLUSIONS: Despite 2 complicated cases, intraoperative perforation during DALK had a good final functional prognosis. However, eyes in which the perforation required reformation of the anterior chamber had a mean endothelial cell loss greater than 20%. When air is left in the anterior chamber, close monitoring is required to avoid pupillary block.