Long-term assessment of tilt of glued intraocular lenses: an optical coherence tomography analysis 5 years after surgery.

PURPOSE: Long-term assessment of the optic position of glued transscleral fixated intraocular lens (IOL) with optical coherence tomography (OCT). DESIGN: Prospective observational case series. PARTICIPANTS: Patients with a minimum 5 years' follow-up after glued IOL surgery were included. METHODS: Postoperatively, IOL position was examined by anterior segment OCT (Carl Zeiss Meditec) and the scans were analyzed in 2 axes (180°-0° and 270°-90°) using MatLab (Mathworks). Best-corrected visual acuity (BCVA; Snellen's charts), Orbscan, retinoscopy, refraction, and slit-lamp biomicroscopy were performed. MAIN OUTCOME MEASURES: The distance between the iris margin and the anterior IOL optic (D1, D2), slope of the line across the iris and IOL, the slope ratio between the IOL and iris, IOL tilt, and optic surface changes were determined and correlated with the astigmatism and vision. RESULTS: A total of 60 eyes (mean follow-up of 5.9±0.2 years; range, 5-6 years) were evaluated. There was a significant correlation (P = 0.000) between the slope of iris and the IOL in horizontal and vertical axes. The mean D1 and D2 were 0.94 ± 0.36 and 0.95 ± 0.36 mm, respectively. Nine of 60 eyes (15%) had pigment dispersed on the IOL surface. Twenty-one eyes (35%) had optic tilt detected on OCT and 65% of eyes had no optic tilt. The mean angle between the IOL and the iris was noted to be 3.2 ± 2.7° and 2.9 ± 2.6° in horizontal and vertical axes, respectively. The mean ocular residual astigmatism (ORA) was 0.53 ± 0.5 diopters. There was no difference in the ORA between the eyes with and without tilt (P = 0.762). There was no correlation (P = 0.348) between the ORA and BCVA. Position of the IOL was not dependent on the type of lens, age of the patient, or the preoperative surgical indication. CONCLUSIONS: Long-term analysis with OCT demonstrated good IOL positioning without any significant optic tilt in patients with glued IOL fixation.

Modified technique for combining DMEK with glued intrascleral haptic fixation of a posterior chamber IOL as a single-stage procedure.

PURPOSE: To describe changes in the surgical technique required for combining Descemet membrane endothelial keratoplasty with glued intrascleral haptic fixation of a posterior chamber intraocular lens ([IOL] glued IOL) as a single-stage surgery in patients diagnosed as having aphakic or pseudophakic bullous keratopathy. METHODS: Six patients with corneal decompensation and inadequate capsular support requiring implantation/exchange of an IOL underwent a single staged glued IOL with Descemet membrane endothelial keratoplasty at a tertiary care center. Stability of the anterior chamber and structure of iris diaphragm-IOL complex were assessed intraoperatively by injecting air and, when required, iridoplasty was performed. Patients were observed postoperatively. RESULTS: One patient had partial graft detachment requiring re-bubbling and 1 patient had a small peripheral detachment with spontaneous resolution. The graft remained attached in all patients. An iridoplasty was required for 2 patients. Visual acuity improved in all patients. The mean preoperative and postoperative corrected distance visual acuity were 0.11 ± 0.07 and 0.7 ± 0.17, respectively. There was significant change in the corrected distance visual acuity after surgery (P = .028). The mean postoperative endothelial cell density at 6 months was 1,710.3 ± 205.8 cells/mm(2). CONCLUSIONS: Descemet membrane endothelial keratoplasty with glued IOL provides stable IOL with decreased pseudophacodonesis for better graft fixation. Iris diaphragm covering IOL optic all around is essential to restore bicamerality, allows sufficiently sized, non-migrating air bubbles, and decreases graft detachment and dislocation both intraoperatively and postoperatively. A need for iridoplasty must be confirmed intra-operatively.

Clinical outcomes of glued transscleral fixated intraocular lens in functionally one-eyed patients.

PURPOSE: To analyze the indications, visual outcome, mental status, and quality of life after glued transscleral fixated intraocular lens (IOL) in functionally one-eyed individuals. SETTING: Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective observational comparative case series. METHODS: Patients with one functioning eye with surgical indications (aphakia, luxated IOL, or dislocated lens) and the fellow eye with no perception of light were included. Indications, uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), mental status (Amsterdam Preoperative Anxiety and Information Scale) and quality of life (visual function scoring VF-14) were assessed. Outcomes of nonsurgical and surgical management were evaluated and compared. RESULTS: Of 22 patients, 10 (45.4%) patients underwent glued IOL (group A) and 12 (54.5%) wore spectacles (group B). There was a strong association between the initial clinical presentation and management (χ, P=0.000). Subluxated cataract and dislocated lens (or IOL) required surgical treatment. Postoperative aphakia with adequate spectacle correction were conservatively treated. There was change (P=0.005) in UDVA and CDVA after glued IOL surgery. There was no loss of CDVA. There was difference between the 2 groups in reading small prints (P=0.021), sporting activities (P=0.000), and night driving (P=0.000). Surgical anxiety was higher in group B (P=0.014). Females were more anxious than the males (P=0.014). There was an association of increasing age and the decision for nonsurgical management (χ, P=0.005). CONCLUSION: Glued transscleral fixated IOL can be safely performed in one-eyed patients for specific indications to provide good functional results.

Clinical outcomes of intraocular lens scaffold surgery: a one-year study.

PURPOSE: To evaluate the safety and 1-year outcome of the intraocular lens (IOL) scaffold technique in eyes with soft to moderate nuclear remnants after intraoperative posterior capsule rupture (PCR). DESIGN: Single-center, retrospective, interventional, noncomparative, consecutive case series. PARTICIPANTS: A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic. METHODS: A retrospective analysis of medical records of a consecutive series of patients who underwent IOL scaffold surgery from August 2011 to February 2013 was reviewed. All surgeries were performed by a single surgeon, and a 3-piece, 6.0-mm optic, acrylic, foldable IOL with a modified C-loop haptic configuration was implanted in all eyes. MAIN OUTCOME MEASURES: The preoperative and postoperative parameters evaluated were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), specular microscopy, gonioscopy, ultrasound biomicroscopy, central macular thickness, intraocular pressure (IOP), and anterior and posterior segment inflammation. The final visual outcome at 1 year was evaluated. RESULTS: At 1-year follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.58 ± 0.15 and 0.90 ± 0.17, respectively. The IOL was placed in the sulcus for 14 eyes and in the capsular bag for 3 eyes, and glued intrascleral fixation of IOL was performed in 3 eyes. The mean postoperative refractive error at the final examination was -0.4 ± 0.05 diopter (standard error of mean). Postoperative CDVA of 20/20 and 20/30 was achieved in 75% (15 eyes) and 25% (5 eyes), respectively. There was no correlation between preoperative specular count and percentage loss of cells (P = 0.602; r(2)=0.015). The mean central macular thickness at 1 year was 182.5 ± 11.79 µm. Clinical macular edema was observed in 1 of 20 eyes (5%). CONCLUSIONS: The IOL scaffold provided an effective, relatively noninvasive means of emulsifying moderate to soft nuclear remnants in eyes with intraoperative PCR, with a good visual outcome and a favorable complication rate.

Rotational lamellar scleral flap for the management of posttrabeculectomy bleb leak.

We describe a technique of rotational lamellar scleral flap for surgical repair in cases of posttrabeculectomy aqueous leak in patients with button holing or necrosis of the trabeculectomy flap. A rotational scleral flap is marked out from the sclera adjacent to the trabeculectomy site followed by a lamellar dissection to fashion the flap. Relaxing cuts are made at the base of the flap so as to ensure that the rotation flap adequately covers the site of aqueous leak. This flap is then secured to the underlying sclera and the cornea at the limbus.

Endothelial cell loss associated with diffuse lamellar keratitis because of laser-assisted in situ keratomileusis.

PURPOSE: To report a case of severe interface inflammation, flap edema, and endothelial cell loss after laser-assisted in situ keratomileusis (LASIK). METHODS: A 22-year-old woman with no previous ocular abnormality underwent LASIK for myopia. The surgery was uneventful. Her preoperative endothelial count was 3,066 and 2,898 cells per square millimeter OD and OS, respectively. RESULTS: On the first postoperative day, the right eye had interface infiltrates, flap edema, and radiating Descemet's folds and the left eye had flap edema with interface infiltrates. Bilateral flap relifts and thorough irrigation were performed on the second day, followed by amputation of the nonviable flap in the right eye on the third day. On medical management, the corneal edema resolved for more than 1 month. At 6 months, the best-corrected vision was 20/32 OD and 20/25 OS, with endothelial cell count of 1,763 and 2,055 cells per square millimeter OD and OS, respectively. CONCLUSIONS: Endothelial status should be monitored in patients with a severe interface reaction or severe diffuse lamellar keratitis after LASIK.

Surface ablation with iris recognition and dynamic rotational eye tracking-based tissue saving treatment with the Technolas 217z excimer laser.

PURPOSE: To evaluate the visual and refractive outcomes and expected benefits of Tissue Saving Treatment algorithm-guided surface ablation with iris recognition and dynamic rotational eye tracking. METHODS: This prospective, interventional case series comprised 122 eyes (70 patients). Pre- and postoperative assessment included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refraction, and higher order aberrations. All patients underwent Tissue Saving Treatment algorithm-guided surface ablation with iris recognition and dynamic rotational eye tracking using the Technolas 217z 100-Hz excimer platform (Technolas Perfect Vision GmbH). Follow-up was performed up to 6 months postoperatively. Theoretical benefit analysis was performed to evaluate the algorithm's outcomes compared to others. RESULTS: Preoperative spherocylindrical power was sphere -3.62 ± 1.60 diopters (D) (range: 0 to -6.75 D), cylinder -1.15 ± 1.00 D (range: 0 to -3.50 D), and spherical equivalent -4.19 ± 1.60 D (range: -7.75 to -2.00 D). At 6 months, 91% (111/122) of eyes were within ± 0.50 D of attempted correction. Postoperative UDVA was comparable to preoperative CDVA at 1 month (P=.47) and progressively improved at 6 months (P=.004). Two eyes lost one line of CDVA at 6 months. Theoretical benefit analysis revealed that of 101 eyes with astigmatism, 29 would have had cyclotorsion-induced astigmatism of ≥ 10% if iris recognition and dynamic rotational eye tracking were not used. Furthermore, the mean percentage decrease in maximum depth of ablation by using the Tissue Saving Treatment was 11.8 ± 2.9% over Aspheric, 17.8 ± 6.2% over Personalized, and 18.2 ± 2.8% over Planoscan algorithms. CONCLUSIONS: Tissue saving surface ablation with iris recognition and dynamic rotational eye tracking was safe and effective in this series of eyes.

A prospective randomized comparison of four femtosecond LASIK flap thicknesses.

PURPOSE: To evaluate the visual outcomes, predictability, and planarity of four types of 60-kHz femtosecond laser-assisted LASIK flaps: 90, 100, 110, and 120 microm. METHODS: This randomized, prospective, interventional, comparative trial was performed at a tertiary care facility. Two hundred forty eyes with a calculated residual bed thickness >300 microm (at 120-microm flap thickness and subjective refraction) were randomized into four flap thickness groups to undergo femtosecond laser-assisted LASIK. Pre- and postoperative assessment included uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), and refraction. Flap thickness was assessed by anterior segment optical coherence tomography on 28 points per flap at 1-month follow-up. Three new indices were devised to assess the predictability and planarity. RESULTS: The baseline parameters were matched. Postoperative vision and refractive outcome were similar in the four groups (P>.05, analysis of variance). The achieved flap thickness was different at each measured point among the groups (P<.05) with standard deviations ranging from +/-3.2 to +/-7.3 microm. The predictability and planarity were satisfactory in all four groups, although the indices were slightly better in the 110-microm and 120-microm groups. No loss of BSCVA or flap complications occurred in the four groups. CONCLUSIONS: The study demonstrated that all four flap thicknesses are relatively uniform in predictability and clinical outcomes.

Translocation of malpositioned posterior chamber intraocular lens from anterior to posterior chamber along with fibrin glue-assisted transscleral fixation.

PURPOSE: A posterior chamber intraocular lens (PCIOL) wrongly placed in anterior chamber (AC) can lead to progressive endothelial loss and damage to angle structures. We describe a sutureless, closed-chamber translocation technique to maneuver a PCIOL from AC into the PC and fixate it transsclerally with fibrin glue in presence of a large posterior capsular rent. METHODS: This is a prospective interventional case series. The participants were three cases of PCIOL in AC with high intraocular pressure and poor uncorrected visual acuity who underwent the translocation surgery successfully. RESULTS: All cases showed improvement in uncorrected visual acuity, with lowered intraocular pressure and no loss in best spectacle-corrected visual acuity till 6 months follow-up. CONCLUSIONS: This technique prevents a large incision, does not require a special IOL as in transscleral suture fixation, and results in a low endothelial cell loss.

The three-pass-underpass technique: a graded flap dissection technique for thin femtosecond sub-bowman keratomileusis flaps.

PURPOSE: Femtosecond laser-assisted sub-Bowman keratomileusis has an occasional intraoperative complication of a flap tear. We describe a new technique (three-pass-underpass technique) to dissect and lift the flap to reduce the probability of a tear. METHODS: This comparative case series, 150 consecutive cases of femtosecond-assisted flap creation for laser in situ keratomileusis underwent flap separation with the new (three-pass-underpass) technique. These cases were retrospectively compared with 150 consecutive cases performed with the conventional, single stroke technique. The three-pass-underpass technique is as follows: After docking, centration, and initiation of the femtosecond laser pass, the side cut was opened with the sharp end of the Siebel Spatula. The blunt end was then inserted from temporal side to make the first pass of the spatula, constituting little less than one third of the area to be separated. The second pass of the spatula covered entire pupillary area, and the remaining third was covered by a third pass. The spatula was then inserted under the flap in the centre, and the flap was then freed up to the hinge by a sweeping movement toward the temporal and nasal periphery. RESULTS: Comparable visual-refractive outcomes and lesser flap tear rate were noted with the new technique compared with the conventional technique. CONCLUSIONS: The three-pass-underpass technique seems to be a safe alternative to the conventional single-stroke technique for dissecting sub-Bowman flaps.

Anterior segment transplantation with a novel biosynthetic graft.

PURPOSE: Staphylectomy with sclerokeratoplasty has been performed in cases with large anterior staphyloma. This report describes a technique using a new biosynthetic graft to simulate the anterior segment in the eye of a 4-month-old child with diffuse anterior staphyloma and cataractous lens with compromised zonules. METHODS: The graft had a biologic part (corneoscleral button) and a synthetic part (aniridia intraocular lens). Two partial thickness flaps and sclerotomies were made in the graft through which the lens haptics were externalized. After staphylectomy and lensectomy of the host, the graft was sutured. After intrascleral tuck of the lens haptics before fibrin glue-assisted flap closure was then done. RESULTS: On the first postoperative day, the child was following light with the operated eye, and closure of the lids and cosmesis were markedly improved. Between the first and fourth month follow-up, and with the normal eye occluded, the child was following light and reaching out for objects. The cornea was clear with no evidence of rejection or failure. At 5 months, a persistent epithelial defect developed, leading by 6 months into a nebulomacular opacity partially obscuring the pupil. At 6 months, the results of the technique are anatomically and cosmetically satisfactory; however, a longer follow-up term will establish the visual benefits. CONCLUSIONS: This technique may provide a suitable cosmetic and anatomic alternative to conventional procedures like staphylectomy with sclerokeratoplasty. It also retains the potential for more effective visual rehabilitation as an intraocular lens has been implanted.

Bilateral spontaneous in-the-bag anterior subluxation of PCIOL managed with glued IOL technique: A case report.

OBJECTIVE: Management of in-the-bag spontaneous bilateral subluxation of posterior-chamber intraocular lens(PCIOL) with sutureless fibrin-glue-assisted PCIOL implantation. METHODS: A patient of retinitis pigmentosa with spontaneous bilateral anterior in-the-bag subluxation of PCIOL was managed by IOL explantation followed by fibrin-glue-assisted sutureless PCIOL implantation. Two partial thickness limbal-based scleral flaps were created about 1.5 mm from the limbus under which sclerotomies were made. Intraocular lens explantation along with capsular bag was performed through the corneo-scleral tunnel incision. Single-piece rigid polymethylmethacrylate 6.5-mm optic IOL was introduced through the limbal wound with a McPherson forceps, both the IOL haptics were externalized under the scleral flap. The haptic ends were tucked in the scleral tunnel made with the 26G needle. Scleral flaps and the conjunctiva were closed with the fibrin glue. RESULTS: Preoperative best corrected visual acuity was 20/80 in the right and 20/120 in the left eye. Patient gained a best corrected visual acuity of 20/30 in both the eyes, with a bilateral stable PCIOL and clear cornea. CONCLUSIONS: Severe capsular contracture causing in-the-bag IOL subluxation in retinitis pigmentosa can be effectively managed with this new technique of sutureless fibrin-glue-assisted PCIOL implantation.

Femtosecond-assisted lamellar keratoplasty in atypical Avellino corneal dystrophy of Indian origin.

PURPOSE: To report a case of Avellino corneal dystrophy (ACD) in a patient of Indian origin treated with femtosecond-assisted lamellar keratoplasty (FALK). METHODS: A 6-year-old male patient presented with severe photophobia with decreased vision for 2 months. A clinical diagnosis of Avellino dystrophy was made after complete examination under anesthesia and FALK was performed. RESULTS: The postoperative period was uneventful with good symptomatic improvement and graft clarity. Histopathological study with special staining, namely Masson trichrome and Congo red stain, of the patient's corneal button showed features of both granular and lattice lesions suggestive of ACD. Genetic analysis showed absence of R124H mutation in BIGH3 gene. No recurrence or exacerbation was noted at 19-month follow-up. CONCLUSIONS: To our knowledge, this is the first case report of clinical, histopathological, microscopic features of ACD in young patient of Indian origin with absence of BIGH3 gene treated with FALK with IntraLase Femtosecond Laser for donor and recipient cuts.

Native means of graft stabilization: Host descemetic scaffolding and wound scaffolding to decrease the risk for graft detachment in DMEK and PDEK.

The main postoperative complication of Descemet membrane endothelial keratoplasty and pre-Descemet endothelial keratoplasty (PDEK) is graft detachment. We report a technique in which the host Descemet membrane or the incision is used for graft scaffolding. The descemetorhexis is created 0.5 mm smaller than the graft from between 1 quadrant to 360 degrees, preferably in two opposite quadrants. Using the Jacob technique of pressurized air infusion (air pump-assisted PDEK), the host Descemet membrane is gently teased from under the graft with a reverse Sinskey hook and allowed to overlap the graft from the posterior aspect in a scaffolding manner. Wound scaffolding within the incision is attained by pulling any overlapping part of the graft into the inner part of the corneal incision instead of allowing it to lie posterior to the inferior lip. Both these scaffolding maneuvers give an extra degree of scaffolding or support that provides graft stability and thereby decreases the risk for graft detachment.

In vivo analysis of wound architecture in 700 microm microphakonit cataract surgery.

PURPOSE: To analyze the clear corneal wound architecture in 700 microm cataract surgery (microphakonit) using anterior segment optical coherence tomography (AS-OCT). SETTING: Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. METHODS: Wound architecture was analyzed by AS-OCT 30 minutes after surgery and 1, 3, and 7 days postoperatively in 12 eyes (11 patients) that had microphakonit surgery. Five eyes had microphakonit with a 700 microm phaco tip with no intraocular lens (IOL) implantation, and 7 eyes had foldable IOL implantation after the main port was extended with a 2.8 mm keratome. RESULTS: Twenty-four clear corneal wounds, which included the main port and the side port, were studied. The mean endothelial misalignment in the microphakonit wound was 0.085 mm +/- 0.09 (SD) immediately postoperatively, 0.057 +/- 0.07 mm at 1 day, 0.020 +/- 0.04 mm at 3 days, and 0.0 mm at 7 days. The mean coaptation loss was 0.030 +/- 0.06 mm immediately postoperatively, 0.029 +/- 0.04 mm at 1 day, and 0.029 +/- 0.04 mm at 3 days. There was a significant positive correlation between the change in stromal hydration and coaptation loss in the 17 wounds without extension; 82.3% of wounds at 3 days and 100% at 7 days had complete endothelial alignment. CONCLUSION: Although there was no significant difference in endothelial misalignment, coaptation loss, or amount of stromal hydration between microphakonit wounds without and wounds with a 2.8 mm keratome extension, wound healing and resolution of coaptation loss or endothelial realignment occurred earlier in wounds without extension.

Modified Malyugin ring iris expansion technique in small-pupil cataract surgery with posterior capsule defect.

We describe a simple technique involving modification of iris expansion with the Malyugin ring (MicroSurgical Technology) in nondilating small-pupil cataract surgery with preexisting posterior capsule defect or intraoperative posterior capsule tear. A 6-0 polyglactin suture is placed in the leading scroll of the Malyugin ring, and the end of the suture is secured at the main port incision. This prevents the iris expander from inadvertently dropping into the vitreous during intraoperative manipulation.

Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules.

We report a new surgical technique that uses biological glue to implant a posterior chamber intraocular lens (PC IOL) in eyes with a deficient or absent posterior capsule. Two partial-thickness limbal-based scleral flaps are made 180 degrees apart diagonally, and the haptics of the PC IOL are externalized to place them beneath the flaps. Fibrin glue is used to attach the haptics to the scleral bed, beneath the flap. This simple method of PC IOL implantation requires no specially designed haptics. It provides good flap closure and IOL centration and stability without suture-related complications.

Mirror telescopic intraocular lens for age-related macular degeneration: design and preliminary clinical results of the Lipshitz macular implant.

PURPOSE: To conduct a pilot study evaluating the visual and surgical outcomes of an intraocular mirror telescopic intraocular lens, the Lipshitz macular implant (LMI) (Optolight Vision Technology), for age-related macular degeneration (ARMD) and other macular pathology. SETTING: Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. METHODS: The LMI was implanted in patients with bilateral macular pathology and visual acuity worse than 20/200 in whom vision improved with a x2.5 external telescope preoperatively. The LMI was implanted after conventional phacoemulsification or microphakonit. The minimum follow-up was 6 months. RESULTS: Six eyes of 6 patients had surgery in the worse eye. Four eyes had ARMD, and 1 eye each had myopic macular degeneration or macular dystrophy. There were no intraoperative complications. The mean gain in distance acuity was 3.66 lines +/- 1.88 (SD), and the mean increase in the Early Treatment Diabetic Retinopathy Study score for near acuity was 50.83 +/- 9.15 logMAR. The best corrected distance acuity and near acuity improved significantly (both P = .014). The mean change in endothelial count was -5.79% +/- -4.07%. The mean postoperative corneal endothelial-LMI distance was 3.15 +/- 0.31 mm. A good central fundus view was possible around the mirrors in all eyes. Fundus fluorescein angiography showed good visibility of the retina up to the midperiphery. The mean score on a quality-of-life questionnaire was 11.16 +/- 1.72 (SD) preoperatively and 4.50 +/- 0.83 postoperatively, a statistically significant improvement (P = .014). CONCLUSIONS: The LMI may be an effective solution for optical rehabilitation of patients with ARMD or other macular pathology by increasing the central image on the retina while preserving peripheral vision. The surgery and visual recovery were quick, and the improvement in quality of life was significant.

Recognizing and Managing Bullous Descemet Detachment Secondary to Accidental Hydroseparation During Phacoemulsification/Cataract Surgery by Relaxing Descemetotomy.

PURPOSE: To report a new technique called relaxing Descemetotomy for treatment of bullous Descemet detachment (BDD) secondary to accidental hydroseparation of Descemet membrane (DM) during stromal hydration in cataract surgery. METHODS: A clear corneal keratome entry was created close to the limbus extending inward to create a relaxing cut (ab externo relaxing Descemetotomy) on taut DM, thus creating an egress route for supra-Descemetic fluid (SDF). This was followed by pneumodescemetopexy to drain SDF internally. RESULTS: Three patients with a history of unsuccessful pneumodescemetopexy and with planar or mildly convex separation of DM without break on anterior segment optical coherence tomography (ASOCT) underwent this procedure. All had successful reapposition of DM clinically and on ASOCT. All showed resolution of stromal edema and improved uncorrected and best-corrected visual acuity postoperatively. CONCLUSIONS: Rarely stromal hydration performed with an irrigating cannula positioned too close to the posterior stroma can result in hydroseparation of DM creating BDD, seen intraoperatively as a fluid wave propagating across the posterior aspect of the cornea. Large folds, free mobility, and DM tear classically seen with rhegmatogenous Descemet detachment are not seen clinically or on ASOCT in BDD. Pneumodescemetopexy alone cannot resolve BDD because without a DM tear, SDF cannot evacuate. Combining relaxing Descemetotomy with pneumodescemetopexy allows SDF to drain internally and Descemet detachment to resolve. This technique has numerous advantages over classical venting incisions in terms of ease, preferable limbal location, larger incision size, absence of complications such as visual axis scars, irregular astigmatism, epithelial ingrowth, infectious keratitis, etc.