Advanced DALK Techniques: Mushroom Mini Big Bubble DALK

Deep anterior lamellar keratoplasty (DALK) carries advantages over penetrating keratoplasty (PK) by eliminating donor endothelial rejection and graft decompensation, the leading cause of PK failure. Consequently, DALK in conditions with a healthy host endothelium such as keratoconus improves graft survival. However, DALK is a difficult surgery with a high intraoperative conversion rate to PK due to Descemet membrane (DM) particularly during peripheral DM baring. Through automating stages of DALK with a femtosecond laser to create a 3D mushroom configuration and utilizing a mini big bubble to reduce the area of DM baring to within the confines of the pre-Descemet layer, the risk of intraoperative perforation and conversion to PK can be reduced.