**6.4 Hemorrhage in the interface**

A noticeable amount of bleeding in the interface due to preexisting corneal vascularization should be managed by washing and cleaning the interface because residual blood in the interface may result in interface opacity.

#### **6.5 Hyphema**

Because the paracentesis is made in a semivertical direction to not violate the DM, introducing an instrument into the anterior chamber can cause injury to the iris tissue and hyphema (Figure 22).

A small peripheral iridotomy will not guarantee that the patient will not experience a relative papillary block if the air bubble is so large or if expanding gas such as SF6or C3F8

Double anterior chamber occurs when a perforation is present in the recipient's bed. If the amount of fluid in the interface is minimal, the condition can be managed by observation alone. If not, the intracameral injection of air or gas (SF6or C3F8) and the drainage of the interface fluid can manage the condition. Great care must be taken to not inject air over the

Foreign particles in the interface can be left in place without any attempt to remove them if there has been no associated inflammation and edema and they have been out of the optical

Small filaments in the interface do not affect the visual acuity even if they are located within

A noticeable amount of bleeding in the interface due to preexisting corneal vascularization should be managed by washing and cleaning the interface because residual blood in the

Because the paracentesis is made in a semivertical direction to not violate the DM, introducing an instrument into the anterior chamber can cause injury to the iris tissue and

DM in the interface. Every effort must be made to prevent papillary block.

Fig. 21. One piece of sponge entraped in the donor\_ host interface.

is used.

**6.2 Double anterior chamber** 

zone of the cornea (Figure 21).

the optical zone.

**6.5 Hyphema** 

hyphema (Figure 22).

**6.4 Hemorrhage in the interface** 

interface may result in interface opacity.

**6.3 Foreign particles within the interface** 

Fig. 22. Introducing surgical devices into the anterior chamber may be accompanied with hyphema.

Management includes gentle washing of the anterior chamber for flouting red blood cells after cardinal sutures are placed using a blunt-tipped cannula and irrigating the BSS through the paracentesis wound and depressing the posterior lip of the wound to drain the blood. Introducing any instrument into the anterior chamber may violate the peripheral DM and turn the condition into a major complication.

### **6.6 Corneal intrastromal cyst**

This rare condition results from proliferation of the epithelial cells in the interface. Management includes removing donor tissue, scrapping and irrigating the recipient's bed, and performing a new graft.

## **6.7 Infectious keratitis**

Peripheral wound infection is accompanied by edema, infiltration, loosening of sutures, and occasionally melting of the cornea. The loose sutures must be removed and placed in culture media along with suitable specimens for recognition of the etiologic organism. The treatment is similar to that for an infectious corneal ulcer. Fungal elements may cause deep ulcers without surface involvement. However, involvement of the donor—recipient interface with an infectious process requires donor tissue removal, vigorous treatment of the recipient's bed, and a new graft (Thomas & Purnell, 1965).

#### **6.8 Allograft stromal and epithelial rejection**

Stromal allograft rejection may occur after successful DALK surgeries and can be accompanied by segmental corneal edema and thickening and corneal stromal vascularization (Figure 23).

Manual Deep Anterior Lamellar Keratoplasty 75

experts. The expanding-bubble modification of the big-bubble technique is the one I consider most useful for routinely performing DALK surgery. I hope it will assist corneal

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I appreciate and thank Arash Daneshgar for his technical support.

**8. Acknowledgment** 

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France, September 18-22, 2004.

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**9. References** 

Fig. 23. Allograft corneal stromal rejection associated with vascularization and segmental corneal edema.

Epithelial allograft rejection is clinically less problematic than other types of allograft rejections. However, management includes aggressive steroid therapy to control and reverse the process. Segmental thickening of the cornea may take a long time to resolve after quiescence of the rejection process. Rarely, graft failure that requires regrafting occurs.
