Case Report
Triple Anterior Chamber after Deep Anterior Lamellar Keratoplasty
Banu Torun Acar* and Suphi Acar
Department of Ophthalmology, Bati Göz Hospital, Turkey
*Corresponding author: Banu Torun Acar , Department of Ophthalmology, Bati Göz Hospital, Kavakli sok. Menekse ap. N0.22 D.14 Caddebostan/Istanbul, Turkey
Published: 25 Aug, 2016
Cite this article as: Acar BT, Acar S. Triple Anterior
Chamber after Deep Anterior Lamellar
Keratoplasty. Ann Clin Case Rep. 2016;
1: 1103.
Abstract
Aim: To report a case of triple anterior chamber (TAC) development and treatment after deep
anterior lamellar keratoplasty (DALK).
Case Reports: A 30-year-old male with granular dystrophy underwent DALK using lamellar
dissection in his right eye. Microperforation occurred during surgery. Viscoelastic was injected into
the anterior chamber to create sufficient tonus. Air was injected into the anterior chamber at the
end of the operation. Post-operative day one, TAC was observed by biomicroscopy and OCT. We
suspected a viscoelastic leftover at the interface. Then, sutures were removed, the space between
the graft and recipient bed washed, and re-sutured. The detachment was resolved, and a relieved
Descemet’s membrane was demonstrated by OCT.
Conclusions: Triple anterior chamber treatment due to the leakage of viscoelastic through
micro perforation cannot be taken in control with air/gas injection. The surgical intervention is
unconditionally necessary because the viscoelastic must be completely removed by irrigating.
Keywords
Deep anterior lamellar keratoplasty; Descemet’s membrane; Optical coherence tomography; Triple anterior chamber
Introduction
Over the last few years, deep anterior lamellar keratoplasty (DALK) has been highly preferable in
cornea pathologies where the endothelium is healthy [1]. It has several advantages when compared
to penetrating keratoplasty (PK). Since DALK is an extraocular surgery, the risk of intraocular
complications such as endophthalmitis, iris/lens damage, and expulsive hemorrhage are quite low
[2]. The loss of endothelial cells during DALK is minimized, and endothelial rejection is eliminated
[1,3]. Nevertheless, DALK is a technique that the learning process is longer and more difficult to
be performed, moreover it is technically more challenging compared to PK [2,3]. One of the most
common complications in DALK is Descemet’s membrane perforation. Due to the extra space
between the graft and the recipient bed, which is a result of Descemet’s membrane perforation, a
double anterior chamber may develop [1]. Although a double anterior chamber is generally stated
that it is withdrawn spontaneously, the anterior chamber occasionally requires the injection of air
[1]. Nevertheless, there could be some cases in which the residual of stroma on recipient bed can
be observed and the microperforation upsurges as result of failing in the occurrence of big bubble.
In other words, in failure of big bubble developing circumstances, the big bubble cannot contact to
the Descemet’s membrane and it causes two additional spaces which are called as “Triple Anterior
Chamber”. In practice, those spaces can be explicitly determined by using Optical Coherence
Tomography (OCT).
In 2002, Anwar and Teichmann [4] defined the “big bubble technique”, which is generated by
injecting air into the corneal stroma after partial trepanation. This technique enables the separation
of Descemet’s membrane from the stroma with low level risk of perforation.
We report a patient having a developed triple anterior chamber following Descemet’s membrane
perforation after deep anterior lamellar keratoplasty.
Case Presentation
A 30-year-old male had bilateral granular dystrophy. The best corrected visual acuity (BCVA)
of him was 20/200 in the right eye and 20/100 in the left eye. DALK was performed on his right eye
under sub-Tenon’s anesthesia (by B.T.A). The trephination was performed by including 60-80 % of
the corneal thickness to reach the deep lamellar tissue by using a Hessburg-Barron vacuum trephine (Jedmed Instrument Co., England). A 30 G needle was connected to a
5-ml plastic syringe filled with air, and advanced 3-4 mm from the site
of incision to the center of the corneal stroma. Assuming a posterior
position of that Descemet’s membrane, air was injected to create a
big bubble. The operation continued with lamellar dissection, as we
were unable to form the bubble. The stromal tissue was dissected
from the Descemet’s membrane by using a blunt iris spatula. Some
of the stroma left on the recipient bed. The detached stroma was
cut by using blunt-tipped Vanna’s scissors, however a Descemet’s
membrane perforation was observed at the inferior. Viscoelastic
(Healon, Pharmacia and Upjohn, Peapack, N.J., USA) was injected
from the site of paracentesis into the anterior chamber in order to
create sufficient tonus thereby the remaining tissue was completely
removed. Descemet’s membrane and the endothelium of the donor
cornea were removed by using a fine-tipped tying forceps; thereafter
by using a Baron vacuum donor punch (Katena Products Inc., USA)
trephination was performed to achieve a graft 0.5 mm larger than
the recipient bed and it was sutured the cornea to the recipient bed
using 10-0 nylon sutures. Viscoelastic was drained from the site of
paracentesis, and the operation was completed by injecting air into
the anterior chamber.
On the first post-operative day, slit-lamp biomicroscopy revealed
an edematous graft and extra spaces separated by membranous tissue,
which formed a triple anterior chamber (Figure 1). An extra space
was observed between the graft and the host tissue; a membranous
tissue formed another extra space posterior to the recipient bed.
The extra spaces were examined in detail using optical coherence
tomography (OCT) (Optovue, Inc., Fremont, CA, USA) (Figure 2). It was assumed that the viscoelastic given to the anterior chamber
during the operation accumulated in the area between the graft and
the recipient residual stroma due to microperforation, which in
turn caused the formation of the first extra space (Figure 2). On the
other hand, it was believed that the second space formed between
the residual stroma on recipient bed and the Descemet’s membrane
of the recipient was a result of Descemet’s membrane detachment
(Figure 2). A period of time was given for the extra spaces to resolve
spontaneously before proceeding with surgical intervention. It was
thought that, the air in the anterior chamber could resolve the triple
anterior chamber. However, there was no improvement until postoperative
day seven; therefore, an additional operation was scheduled
accordingly. Five sutures between the 10 o'clock and 2 o'clock position
were removed. The interface between the graft and the recipient
were irrigated with a sufficient volume of liquid, and the viscoelastic
displacement was observed. Five single sutures were replaced. The
anterior chamber was formed and an air tamponade was performed
to fill the anterior chamber completely. Although air was observed in
the upper anterior chamber on 24th hour post-operatively, the extra
spaces were not visible in slit-lamp biomicroscopy. The air was fully
absorbed on post-operative day three, and by using OCT, we observed
that all spaces were lost, and the apposition between the graft and the
recipient bed was maintained (Figure 3). A decrease in the corneal
edema was observed in the follow-ups. The graft was completely
clear on the third month after DALK meanwhile the patient’s CVA
increased to 20/40. Six months after the operation, the patient had
2592 cells/mm². The slit lamp biomicroscopy image at post-operative
month six is presented in (Figure 4).
Discussion
DALK is a highly reliable and effective technique in cornea
pathologies where the endothelium is healthy. DALK has a number
of advantages compared to PK some of which are earlier patient
rehabilitation, minimum risk of graft rejection, and less intraoperative and postoperative complications [1-4].
Although various surgical techniques are practiced for DALK,
one of the most frequent complications is Descemet’s membrane
perforation that occurs during deep stromal layer dissection [1,4].
Descemet’s membrane detachment following perforation results
in a double anterior chamber in the postoperative period. Some
patients are prone to Descemet’s membrane detachment due to weak
adhesion between the stroma and the Descemet’s membrane [5]. It
was stated that weak adhesion resulted from mutated TGF-B1 gene
dysfunction [6]. In addition, it was reported that during surgery with
the viscodissection technique, which is one of the DALK techniques,
viscoelastic was sequestrated among non-dissected layers of the
receptive cornea or between Descemet’s membrane and the stroma
[7]. Sugita et al. [1] clarified that during surgery, microperforation
developed due to stromal opacification in 47 eyes out of 120 in which
DALK was performed; Descemet’s membrane detachment or double
anterior chamber occurred only in 14 of those cases. These cases were
treated by injecting air into the anterior chamber or draining the
aqueous space.
In our case, the surgery was started to perform big bubble
technique however continued with lamellar dissection. Descemet’s
membrane perforation occurred during the surgery and continued
by injecting viscoelastic into the anterior chamber. Why did a triple
anterior chamber occur in this case, while a double anterior chamber
is generally observed in cases where microperforation develops? The
reason is that the viscoelastic which was injected into the anterior
chamber leaked from the perforation site and spread to the space
between the graft and the recipient residual stroma and the first extra
space is achieved accordingly. An additional space occurred between
the recipient residual stroma and Descemet’s membrane of the
recipient as a result of microperforation.
In the literature, it is stated that Descemet’s membrane
detachment usually regresses spontaneously [8-10]. Hirano et al. [6]
reported that in their case that Descemet’s membrane detachment
recovered spontaneously during the first week, and the extra space
between the graft and the recipient bed recovered spontaneously on
the third week.
On the other hand, repairing Descemet’s membrane detachment
in the early stage is claimed to provide a better reposition [10,11].
The practice of different methods to relieve Descemet’s membrane
detachment is still debated. A rolled Descemet’s membrane can be
opened by injecting viscoelastic, thereafter saline replacement follows,
and finally the gas injection process is applied [12]. Ellis and Cohen
[13] used intracameral SF6 to resolve the Descemet’s membrane
detachment, while Mannan et al. [14] used intracameral C3F8 gas, due
to its long-lasting effect.
In our case, we believed that we would be unable to resolve
the Descemet’s membrane detachment with only intracameral gas
injection, due to the presence of the viscoelastic between the graft
and the recipient bed. Thus, the interface was irrigated at first, and
then injected with intracameral air. During postoperative followups,
we observed that the extra spaces disappeared thoroughly and
the air inside the anterior chamber was resorbed. Bhojvani et al. [7] stated that in complications following DALK with the viscodissection
technique, viscoelastic inside the interface would not be resolved
spontaneously and irrigation is necessary for treatment.
Despite the complication, the patient’s BCVA increased to 20/40 in
the post-operative sixth month, and there was no significant decrease
in the number of endothelium. DALK is a successful technique that
yields good results, as long as the complications that occur during
the operation are treated accordingly. In conclusion, there is a need
for an urgent second surgical intervention instead of waiting for the
spontaneous resolution of Descemet’s membrane detachment.
Figure 1
Figure 1
Postoperative first day slit lamp biomicroscopy findings, edema in
the graft and extra spaces separated with membranous tissue forming triple
anterior chamber.
Figure 2
Figure 2
Postoperative first day OCT documentation of the extra spaces
forming a triple anterior chamber.
A: First extra space (viscoelastic between the graft and the recipient bed).
B: Second extra space (humor aqueous between the recipient bed and
Descemet’s membrane).
Figure 2
Figure 2
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