Modified Instrumentation to Simplify

“Big Bubble technique” for Deep Anterior Lamellar

Keratoplasty (DALK)

Dr Rajesh Fogla DNB, FRCS, MMed

Senior Consultant, Corneal Surgeon

Apollo Hospitals, Hyderabad, INDIA

dr_fogla@yahoo.com

www.corneaclinic.com

Financial Interest : No Financial InterestThe Fogla DALK instruments were developed by Storz (B&L) free of cost

Big Bubble Technique DALK

• First described by Dr Mohammed Anwar

• Technique uses forceful injection of air at 80%

corneal depth using 27G needle connected to

an air filled syringe

• Air pressure results in separation of the

Descemet Membrane (DM) from stroma.

• Edge of DM separation is outlined with a dense

white band

• This allows replacement of pathological stroma

with donor tissue devoid of DM.

Big Bubble Technique DALK

• Original technique - Steep learning curve

• Technique requires placement of sharp 27G needle at

> 80% depth of cornea.

• Superficial placement of needle tip results in stromal

emphysema and lateral movement of air towards the

limbus

• Deeper placement of needle tip increases risk of

perforation into the anterior chamber

• Success rate of achieving Big Bubble is 65-80% even in

hands of experienced surgeons

Modified Instruments for Big Bubble DALK Surgery

Deflating the Big Bubble using sharp 15 blade with cutting edge facing upwards

Using the Fogla Trifacet spatula the space in between the stroma and DM is entered, and the overlying stroma incised using No 15 blade to enlarge the opening

Using Fogla R & L Scissors, the overlying stroma is split into 4 quadrants

Using Fogla R & L Scissors, each quadrant of stromal tissue is excised carefully at the edge of corneal trephination

Note bare DM after excision of stromal tissue, Donor tissue is prepared by peeling off DM using fine tying forceps, Donor tissue is placed on the host bed and sutured using 10-0 Nylon suture

Post operative outcome is excellent following Big Bubble technique of DALK surgeryThis technique also allows better utilization of donor tissues from the Eyebank

Modified Technique & Instrumentation

• Instruments designed in 2006

• Over 200 consecutive DALK procedures performed since then

• Big Bubble achieved in > 95% cases

• Microperforation occurred in 1.5% cases (3)

• None of the cases converted to penetrating keratoplasty

• Average uncorrected visual acuity 20/60, best spectacle

corrected visual acuity of 20/25.

Conclusion

• Modified Big Bubble technique of DALK surgery is easier to

master with lower complication rates using the Fogla set of

DALK instruments.

• Surgeons will now be able to apply this surgical technique to a

wide variety of corneal disorders with healthy endothelium

requiring corneal transplantation surgery

Thank You

www.corneaclinic.com