title: Deep anterior lamellar keratoplasty--triple procedure: a useful clinical application of the pre-Descemet's layer (Dua's layer).
abstract: OBJECTIVE
  To describe a technique which exploits the transparency and toughness of the pre-Descemets layer (Dua's layer) to safely perform deep anterior lamellar keratoplasty (DALK) and phacoemulsification at the same time.
  
  
  METHODS
  Three DALK procedures combined with phacoemulsification were performed by the same surgeon using the big-bubble (BB) technique at the Research Institute of Ophthalmology, Cairo, Egypt. In two cases a type-1 BB, baring Dua's layer, was achieved and in one case a type-2 BB, baring the Descemet's membrane (DM), was achieved. The surgeries were video recorded and photo slit-lamp images were taken in the follow-up visits.
  
  
  RESULTS
  DALK with phacoemulsification and lens implant was carried out in both patients where a type-1 BB was achieved. At a follow up of 18 months (first case) and 6 months (second case), the best corrected vision was 6/12 for each. In the case where a type-2 BB was achieved, the DM ruptured during injection of viscoelastic prior to capsulorhexis. The procedure was converted to a penetrating keratoplasty without phacoemulsification.
  
  
  CONCLUSIONS
  When a type-1 BB is achieved simultaneous DALK and phacoemulsification can be safely accomplished. Dua's layer allows a clear view for performing phacoemulsification with the added benefit of its toughness, which can maintain a stable anterior chamber for cataract surgery. This should not be attempted when a type-2 BB is achieved.
authors.affiliation: Research Institute of Ophthalmology, Cairo, Egypt.
authors.forename: A A
authors.initials: AA
authors.lastname: Zaki
authors.affiliation: 1] Research Institute of Ophthalmology, Cairo, Egypt [2] Academic Ophthalmology, Division of Clinical Neuroscience, B Floor, Eye ENT Centre, Queens Medical Centre, University of Nottingham, Nottingham, UK.
authors.forename: M S
authors.initials: MS
authors.lastname: Elalfy
authors.affiliation: 1] Research Institute of Ophthalmology, Cairo, Egypt [2] Academic Ophthalmology, Division of Clinical Neuroscience, B Floor, Eye ENT Centre, Queens Medical Centre, University of Nottingham, Nottingham, UK.
authors.forename: D G
authors.initials: DG
authors.lastname: Said
authors.affiliation: Academic Ophthalmology, Division of Clinical Neuroscience, B Floor, Eye ENT Centre, Queens Medical Centre, University of Nottingham, Nottingham, UK.
authors.forename: H S
authors.initials: HS
authors.lastname: Dua
mesh_terms: D002386:Cataract / Q000150:complications*; D003316:Corneal Diseases / Q000150:complications*; D003319:Corneal Stroma / Q000601:surgery; D016039:Corneal Transplantation / Q000379:methods*; D003886:Descemet Membrane / Q000601:surgery*; D006801:Humans; D019654:Lens Implantation, Intraocular / Q000379:methods*; D008297:Male; D008875:Middle Aged; D018918:Phacoemulsification / Q000379:methods*; D066167:Slit Lamp; D014741:Video Recording; D014792:Visual Acuity / Q000502:physiology; D055815:Young Adult