TRIPLE ANTERIOR CHAMBER: A RARE COMPLICATION FOLLOWING DEEP ANTERIOR LAMELLAR KERATOPLASTY

To report a case illustrating the development of a triple anterior chamber following deep anterior lamellar keratoplasty (DALK) in a patient with macular corneal dystrophy, and its successful management.  

Clinical Emergency Eye Hospital Bucharest

A 38-year-old male patient presented to our hospital with complaints of decrease in vision in both eyes for many years. His best-corrected visual acuity (BCVA) was 20/200 in both eyes. The intraocular pressure (IOP) was normal. Slit lamp examination of both eyes showed round white opacities extending all the way to the limbus with no clear cornea in between. The rest of the ocular examinations was unremarkable. Anterior segment optical coherence tomography (ASOCT) revealed thinning of the cornea and hyperreflectivity that tended to extend to the deep layers. Specular microscopy was not possible. The clinical diagnosis was macular corneal dystrophy and the patient underwent DALK in the right eye. Using the Big Bubble technique, a Big Bubble type 3 was achieved. Manual dissection was performed above the preDescemetic layer (Dua’s), and all the deeper bubbles (type 1 and type 2) were collapsed. A peripheral microperforation of Descemet’s membrane was observed and managed through air descemetopexy. On the first postoperative day, the development of a triple anterior chamber was noted and an air descemetopexy with drainage of the interface fluid was performed. Five days post-rebubble, the patient had a persistent double anterior chamber and diffuse corneal edema. One month postoperatively, BCVA was 20/63 in the right eye, but we noticed a detachment of the posterior lamella which spontaneously attached. Six months postoperatively, BCVA was 20/32 in the right eye, with slit lamp examination revealing inferior focal edema and Descemet’s striae.  

Advances in understanding corneal anatomy and the relationship between the posterior stromal layers and Descemet’s membrane are enhancing our ability to interpret intraoperative procedures and postoperative results in lamellar corneal transplantation.