Purpose: To present some simple surgical maneuvers to manage a type 2 big bubble (BB) in deep anterior lamellar keratoplasty (DALK).
Methods: Four DALK procedures with type 2 or mixed BB were performed. One was in the right eye of a 25-year-old female. The corrected distance visual acuity (CDVA) was 20/200 due to advanced keratoconus. The second case was in a 28-year old male with central-anterior stromal scarring and neovascularization due to infectious keratitis and CDVA <20/400. The third case was in a 20-year-old male with advanced keratoconus and CDVA <20/400. The fourth case was a 49-year-old female, with high irregular astigmatism due to radial keratotomy and her CDVA was 20/150.
Results: At the last follow-up at 12 months, the first case of advanced keratoconus had a clear graft with CDVA = 20/50 and some Descemet\'s folds that were in the visual axis, corresponding to the are of type 2 BB that was not deflated intraoperatively. The second case achieved a CDVA = 20/40, without folds at the visual axis at 12 months of follow-up. In the third and fourth patients with mixed BB where DL was retained, the CDVA was 20/25 and 20/30, respectively. No intraoperative DM perforation or postoperative complications were noted.
Conclusion: Type 2 BB in DALK can be properly managed in order to avoid perforation and to attain a good visual outcome.