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Pseudophakic bullous keratopathy can be managed with a triple procedure technique
The three steps are femtosecond laser-assisted PK, anterior chamber IOL explantation and fibrin glue-assisted sutureless IOL implantation.
 Amar Agarwal |
Pseudophakic bullous keratopathy with an anterior chamber IOL, as seen in Figure 1, is one of the leading causes of full thickness penetrating keratoplasty and IOL exchange. It presents a unique surgical challenge because of a previous complicated surgery, compromised aqueous drainage, unhealthy wound configuration and a deficient posterior capsule. Therefore, both the corneal transplant and the IOL exchange should be optimized to aim at a lesser “open-sky” time, easier intraoperative procedures, earlier wound healing and maximum postoperative preservation of the donor endothelial cells.
In this column, we describe a new triple procedure: femtosecond laser-assisted PK, anterior chamber IOL explantation and fibrin glue-assisted sutureless IOL implantation in the posterior chamber for the management of pseudophakic bullous keratopathy with an anterior chamber IOL. The unique benefits of femtosecond laser and glued IOL could be adjunctive and provide enhanced results in cases undergoing PK and IOL exchange.
Surgical technique
All the procedures were performed under aseptic conditions. The initial part of the surgery was done at the femtosecond facility, and then the patient was shifted on the same wheeled table to the adjoining keratoplasty operating room. Both the donor and recipient corneas were cut with a top hat-shaped wound configuration using a 60 kHz IntraLase FS femtosecond laser (Advanced Medical Optics).
Donor buttons were prepared from whole globes. After the suction ring was applied and adequate vacuum and centration were achieved, a top hat configuration was created (Figure 2). After this, both the donor cornea and the patient were shifted to the keratoplasty operating room.
 Pseudophakic bullous keratopathy with anterior chamber IOL. |
 Femtosecond laser applied on the cornea to create a top hat configuration. |
|
 Explantation of the anterior chamber IOL. |  Glued posterior chamber IOL being fixed. | |
Limited peritomy was done in the inferotemporal and superonasal area 180° apart, and a 3 mm × 3 mm area on the sclera was marked about 1.5 mm from the limbus. Two 3-mm partial-thickness limbal-based scleral flaps were created. Two straight sclerotomies were made with an 18-gauge needle 1.5 mm from the limbus under the existing scleral flaps. After removal of the host button, the anterior chamber IOL was explanted (Figure 3). Limited open-sky anterior vitrectomy was performed.
A posterior chamber 6.5-mm IOL was held with McPherson forceps at the pupillary plane with the left hand. An end-gripping 25-gauge micro-rhexis forceps (MicroSurgical Technology) was passed through the inferior sclerotomy with the other hand. The tip of the leading haptic was grasped with the micro-rhexis forceps and pulled through the inferior sclerotomy following the curve of the haptic (Figure 4). The haptic was then externalized under the inferior scleral flap. The trailing haptic was also externalized through the superior sclerotomy under the scleral flap. After both the haptics were confirmed for adequate exteriorization, the graft was placed and cardinal sutures were applied.
With a 22-gauge needle, a scleral tunnel was created along the curve of the exteriorized haptic in the superonasal area at the edge of the scleral bed of the flap. The haptic was tucked into this tunnel. A similar tunnel was created in the complementary area on the other side, and tucking was performed. Fibrin glue (Tisseel, Baxter) was reconstituted from a pack containing freeze-dried human fibrinogen, freeze-dried human thrombin and aprotinin solution. The reconstituted fibrin glue was injected through the cannula with the double syringe delivery system under the superior and inferior scleral flaps. Local pressure was applied to the flaps for 10 seconds to allow for polypeptide formation. The same glue was applied in areas between the sutures at the entire graft-host junction. The conjunctiva was also apposed with the glue.
Discussion
A sutured scleral-fixated lens hangs on the posterior chamber with the sutures passing through the eye on the haptics. This is like a hammock causing a dynamic torsional and anteroposterior oscillation. This pseudophacodonesis may result into progressive endothelial loss and uveitis-glaucoma-hyphema. However, in our technique, rigid haptics are used for fixation on the scleral side, and the stable optic-haptic junction prevents this torsional and anteroposterior instability. Therefore, there is much lesser pseudophakodonesis.
In suture-fixated IOLs, disintegration and slippage of the knot are potential problems. PMMA is a rigid, durable biomaterial and therefore is a better choice for fixation. This could prevent a reposition surgery and further avoid endothelial cell loss associated with an anterior chamber intervention.
References:
- Agarwal A. Handbook of Ophthalmology. Thorofare, NJ: SLACK Incorporated; 2005.
- Agarwal A. Phaco Nightmares: Conquering Cataract Catastrophes. Thorofare, NJ: SLACK Incorporated; 2006.
- Agarwal S, Agarwal A, Agarwal A. Phacoemulsification –Two volume set. 3rd ed. Informa Healthcare; 2004.
- Amar Agarwal, MS, FRCS, FRCOphth is director of Dr. Agarwal’s Group of Eye Hospitals. Prof. Agarwal is the author of several books published by SLACK, Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery, and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; fax: 91-44-28115871; e-mail: dragarwal@vsnl.com; Web site: www.dragarwal.com.
