Purpose: To report a new complication of spontaneous deflation of type 1 big bubble (BB) in deep anterior lamellar keratoplasty (DALK).

Methods: This is a retrospective review of the surgical videos of BB DALK in 2 cases of advanced keratoconus, wherein spontaneous deflation of type 1 big bubble was noted after removal of air injection cannula. Surgical management and visual outcomes were noted.

Results: After spontaneous deflation of the BB, the first case was managed using a layer-by-layer dissection of the residual posterior stroma to expose pre-Descemet layer. In the second case, a paracentesis was performed to lower intraocular pressure along with reinflation of the type 1 BB, which was followed by standard surgical steps of BB DALK. Both cases accomplished good visual outcome in the postoperative period. Retrospective analysis of the surgical videos revealed possible mechanism of spontaneous deflation.

Conclusions: Spontaneous deflation of type 1 BB can occur after removal of the air injection cannula during DALK, especially in eyes with advanced keratoconus and thin corneas. This complication can be successfully managed without compromising the final visual outcome.

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