Presentation on theme: "Modified Instrumentation to Simplify “Big Bubble technique” for Deep Anterior Lamellar Keratoplasty (DALK) Dr Rajesh Fogla DNB, FRCS, MMed Senior Consultant,"— Presentation transcript:
1 Modified Instrumentation to Simplify “Big Bubble technique” for Deep Anterior Lamellar Keratoplasty (DALK)Dr Rajesh Fogla DNB, FRCS, MMedSenior Consultant, Corneal SurgeonApollo Hospitals, Hyderabad, INDIAFinancial Interest : No Financial InterestThe Fogla DALK instruments were developed by Storz (B&L) free of cost
2 Big Bubble Technique DALK First described by Dr Mohammed AnwarTechnique uses forceful injection of air at 80% corneal depth using 27G needle connected to an air filled syringeAir pressure results in separation of the Descemet Membrane (DM) from stroma.Edge of DM separation is outlined with a dense white bandThis allows replacement of pathological stroma with donor tissue devoid of DM.
3 Big Bubble Technique DALK Original technique - Steep learning curveTechnique 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 limbusDeeper placement of needle tip increases risk of perforation into the anterior chamberSuccess rate of achieving Big Bubble is 65-80% even in hands of experienced surgeons
4 Modified Instruments for Big Bubble DALK Surgery
7 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
8 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
9 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 suturePost operative outcome is excellent following Big Bubble technique of DALK surgeryThis technique also allows better utilization of donor tissues from the Eyebank
11 Modified Technique & Instrumentation Instruments designed in 2006Over 200 consecutive DALK procedures performed since thenBig Bubble achieved in > 95% casesMicroperforation occurred in 1.5% cases (3)None of the cases converted to penetrating keratoplastyAverage uncorrected visual acuity 20/60, best spectacle corrected visual acuity of 20/25.
12 ConclusionModified 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