Predictors of Bubble Formation and Type Obtained With Pneumatic Dissection During Deep Anterior Lamellar Keratoplasty in Keratoconus

Purpose: To identify predictors of bubble formation and type during big-bubble deep anterior lamellar keratoplasty (BB-DALK) performed in keratoconus at different stages of severity. Design: Retrospective Cohort Study. Methods: SETTING: University Magna Græcia (Catanzaro, Italy); STUDY POPULATION: Consecutive keratoconus patients undergoing BB-DALK from September 2014 to February 2019. OBSERVATION PROCEDURE: Keratometric astigmatism, mean keratometry value (K-mean), highest keratometry value (K-max), thinnest point, anterior segment optical coherence tomography (AS-OCT)–based stage of ectasia. MAIN OUTCOME MEASURES: Rate of bubble formation and type; number and fate of micro-/macroperforation; conversion to mushroom keratoplasty (MK); comparison of parameters in patients with bubble formation vs failure and in type 1 vs type 2 bubble; areas under the curves (AUC) of preoperative parameters for distinguishing between bubble types. Results: Pneumatic dissection succeeded in 113 of 155 eyes (72.9%), with 100 type 1 bubbles (88.4%), 11 type 2 (9.8%), and 2 mixed-type (1.8%). Microperforations were managed conservatively in type 1 bubbles; macroperforations occurring in both types of bubbles required conversion to MK. Preoperative K-mean and K-max values were significantly higher in eyes in which bubble formation succeeded (respectively, P = .006 and P <. 013). Type 1 bubbles formed in eyes with significantly lower age, K-mean, and AS-OCT stages and higher pachymetric values (always P <. 029). Age had the highest diagnostic power for discrimination between bubble types, followed by AS-OCT stage, pachymetry, K-mean, and astigmatism (respectively, AUC = 0.861, 0.779, 0.748, 0.700, 0.670). Conclusions: Older age and advanced stages of keratoconus were predictors of type 2 bubble formation during BB-DALK that was associated with an increased risk of complications.