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    AAO 2019 Video Program
    Cornea/External Disease

    Big bubble deep anterior lamellar keratoplasty (BB-DALK) is thought to give better visual outcomes than other DALK techniques. However, it is difficult to achieve BB consistently for the beginner surgeon and also in difficult cases. This video shows a different method of manual DALK technique—“groove, dissect and dissect.” After a 70%-80% depth trephination, 1.5-2.0 mm deep circumferential groove is made using blunt scissors clockwise or anti-clockwise until the pre-Descemet level is reached. Gradually, dissection is carried over toward the center using a blunt-tip iris spatula. The central part is dissected last. The chances of iatrogenic perforations are very low. The visual outcome is good, without any interface haze postoperatively. We demonstrate two examples—in keratoconus with previous hydrops where BB is not possible, and in extremely advanced keratoconus where BB might lead to perforation. Safety margin and good outcomes make this technique a good starting point for beginners