Purpose:

We describe a technique to separate Descemet membrane from the posterior stroma with physiologic saline solution. Its advantage over the big-bubble technique using air is that the procedure is less invasive, is clearly limited in its extensions, and can be better controlled. The Descemet membrane folds provide a clear visualization of the incision to guide it to its required depth.

Methods:

After an initial primary trephination of 8.0 mm down to 90% of the thinnest corneal value, a second smaller trephination is carried out. This port inside the primary circle creates a second entrance into the parenchyma with defined extensions for parenchymal blowup.

The separation of Descemet is then visible as 1 or multiple water pillows. Descemet folds indicate the extent of the separation. Through a side port incision, small air bubbles are injected into the anterior chamber. The water pillow(s) is enlarged and deepened by pushing saline through the remnant stroma. The water pillow is then incised with a special deep anterior lamellar keratoplasty (DALK) cannula.

Results:

Seventy consecutive cases have been performed in the last 12 months, with only 2 perforations (3%). The visual outcomes were equivalent to those achieved in the best cases using the conventional big-bubble technique.

Conclusions:

The water pillow technique offers the advantage of full visualization of the procedure by Descemet folds that are not visible with other techniques.