- Email: [email protected]
Deep anterior lamellar keratoplasty with phacoemulsification
ARTICLE
Deep anterior lamellar keratoplasty with phacoemulsification Anita Panda, MD, FAMS, FICS, FICO, MRCOphth, Harinder Singh Sethi, MD, Mohit Jain, MD, Sasikala Nindra Krishna, DOMS, Anoop Kishore Gupta, MD
PURPOSE: To evaluate the technique and outcomes of deep anterior lamellar keratoplasty (DALK) combined with phacoemulsification for corneal opacity with coexisting cataract. SETTING: Cornea Service, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: Cohort study. METHODS: Eyes with cataract of varied nucleus grade and with different corneal pathologies were selected. Modified triple procedures were performed in all eyes. RESULTS: Twenty eyes were evaluated. The corrected distance visual acuity (CDVA) after 3 months was 20/60 or better in 18 eyes. One eye had 20/80 CDVA as a result of perioperative and postoperative complications. One graft became opaque after postoperative infection. CONCLUSION: Simultaneous DALK with phacoemulsification was feasible in eyes with coexisting corneal and lenticular pathology, and the outcomes were encouraging. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:122–126 Q 2011 ASCRS and ESCRS
Phacoemulsification is considered a modern cataract surgical procedure worldwide. However, the surgeon requires a very clear view during surgery, and this can be hindered by the presence of corneal opacities of any depth. In eyes with cataract and coexisting corneal opacity, there are 2 options. The first is penetrating keratoplasty (PKP) followed by cataract surgery at a later date (2-stage procedure).1 This option provides delayed rehabilitation to the patient and risks endothelial stress. The second option is simultaneous PKP with cataract extraction and intraocular lens (IOL) insertion (triple procedure).2 The triple procedure has several benefits over the 2-stage technique. These include
Submitted: June 19, 2010. Final revision submitted: July 13, 2010. Accepted: July 14, 2010. From Dr. Rajendra Prasad Centre for Ophthalmic Sciences (Panda, Jain, Nindra Krishna, Gupta), All India Institute of Medical Sciences, and Sufdarjung Hospital (Sethi), New Delhi, India. Corresponding author: Anita Panda, MD, D-II/33, Ansari Nagar, New Delhi–110029, India. E-mail: [email protected].
122
Q 2011 ASCRS and ESCRS Published by Elsevier Inc.
a shorter period of visual disability, an overall reduction in the length of the hospital stay, and fewer follow-up visits; thus, the triple procedure is less of a financial burden to the patient. However, a conventional simultaneous triple procedure, although popular, has limitations as well. For example, it is not possible to perform phacoemulsification because of the open-sky recipient window, there is a high risk for radial capsule tear during capsulorhexis, the inherent positive vitreous pressure is cumbersome to the surgeon, there is a greater risk for posterior capsule dehiscence, and cortical cleaning may be inadequate. To obviate these inherent problems of a conventional triple procedure, phacoemulsification is advocated after the corneal opacity is debulked in the anterior corneal lesion,3–5 a temporary corneal graft is placed,6 or keratoprosthesis7 is used during surgery. All 3 options have limitations. We perform a simultaneous triple procedure that varies from the conventional technique in 2 ways. First, we perform deep lamellar keratoplasty (DALK) instead of PKP. Second, we perform phacoemulsification with IOL implantation instead of conventional extracapsular lens extraction. 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2010.07.031
DALK AND PHACOEMULSIFICATION
PATIENTS AND METHODS Patients with deep central corneal lesions and cataract were recruited from the Cornea Clinic, Dr. Rajendra Prasad Centre for Ophthalmic Science, All India Institute of Medical Sciences, New Delhi, India, a tertiary eyecare center. The presence of light projection and accurate perception of rays in all quadrants was a prerequisite in all cases. All eyes were evaluated by ultrasonography and electrophysiologic examination. A detailed slitlamp examination was performed to elucidate the tear meniscus; nature of the vascularization, if any; and depth of corneal lesion invading the posterior stroma. Eyes with tear-film abnormality, stem-cell deficiency, or posterior segment abnormalities were excluded.
Surgical Technique The senior surgeon (A.P.) performed all procedures using peribulbar anesthesia. All surgeries were on an elective basis.
Recipient Bed Preparation To prepare the recipient bed, a 0.4 mm deep mark was made with a 7.5 mm trephine. The mark was slightly eccentric to allow adequate space for the clear corneal tunnel. The anterior lamellar button was removed manually with the help of a lamellar corneal dissector, as previously described.8 Care was taken not to pierce through Descemet membrane. Any remnant of posterior stromal lamellae was removed with caution to achieve a fully transparent Descemet membrane. A high-viscosity ophthalmic viscosurgical device (OVD) was placed over the recipient corneal bed. At no time was saline used to clean the operating field. The operating field was kept dry using a polyvinyl alcohol sponge (Merocel). Phacoemulsification and Intraocular Lens Insertion
Sideport incisions were made at 2 o’clock and 10 o’clock with a microvitreoretinal knife to allow future manipulation. With a 2.7 mm keratome, a clear corneal tunnel was made at the superior cornea (the area at which the maximum recipient clear cornea was available). The anterior capsule was stained with trypan blue injected under the air bubble. The anterior chamber was washed with a balanced salt solution. The OVD was injected into the anterior chamber and the capsulorhexis completed. Complete hydrodissection was performed in the conventional manner. Phacoemulsification was completed by a divide-and-conquer technique. Low vacuum and low flow rates were used throughout the procedure. Complete cortical aspiration was performed using a low aspiration rate. The capsular bag was inflated with OVD and a foldable IOL inserted. The corneal tunnel and side port were hydrated.
Donor Tissue Preparation and Suturing A 7.75 mm donor corneal button was punched from the endothelial side from B-grade McCarey-Kaufman preserved corneal donor tissue. The endothelium was scrapped completely from the button. The recipient bed was rinsed with a saline sponge to remove the OVD, tissue debris, or foreign bodies. The donor button was sutured to the recipient bed with 12-16 monofilament 10-0 nylon sutures with buried knots. A subconjunctival injection of 4 mg dexamethasone and 20 mg gentamicin was given at the end of surgery.
Postoperative Protocol All eyes received topical corticosteroid agents, antibiotic agents, and surface lubricants postoperatively, which were
123
gradually tapered. Patients were followed regularly after discharge as follows: weekly for 2 weeks, once during the next 15 days, once a month for 2 months, and every 3 months thereafter. Graft clarity, anterior chamber status, corneal topography, and specular microscopy were recorded at each visit.
RESULTS The study enrolled 20 eyes of 20 patients. The mean age of the patients was 58.1 years G 6.6878 (SD) (range 55 to 63 years). Table 1 shows the preoperative and postoperative data. In 1 eye, in which the trephine mark was central for a short clear corneal tunnel, fluid leaked from the anterior chamber during maneuvering, which increased recipient corneal hydration and thus hindered visibility. In 2 cases there was posterior capsule rupture; 1 case required anterior vitrectomy and was left aphakic and in the other, a rigid IOL was implanted over the anterior capsule. There were no other intraoperative complications. Although the corneal and the anterior chamber view were not very good at the end of surgery, both were sufficiently clear to allow the graft status and anterior chamber details to be monitored from the first postoperative day onward. All but 1 eye achieved a good visual outcome at the end of 12 weeks (Figure 1). One eye had retained cortical lens matter and had reaspiration of the material 3 days postoperatively. No eye developed postkeratoplasty glaucoma or rejection. DISCUSSION With the invention of modern small-incision sutureless cataract surgery, the popularity of large-incision surgical techniques, such as intracapsular or extracapsular cataract extraction, is fading. Nevertheless, cataract with coexisting corneal opacity of any depth and size is cumbersome to the cataract surgeon during surgery because it hinders visibility. Furthermore, postoperative visual rehabilitation is challenging. Two conventional techniques to manage these cases are available. The first is a 2-stage technique1 in which PKP is followed by cataract surgery at a later date. The second option is simultaneous PKP, cataract extraction, and IOL insertion (triple procedure).2 The former is associated with delayed optical rehabilitation, endothelial stress, and a risk for graft rejection. The triple procedure, thus, is more popular in these cases. However, the modern cataract surgical technique of phacoemulsification is not feasible during this procedure because of the open-sky recipient window. Furthermore, there is a greater chance of posterior capsular tear from positive vitreous pressure and complete aspiration of the cortical matter may not be possible
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
124
DALK AND PHACOEMULSIFICATION
Table 1. Preoperative and postoperative patient data.
Pt
Age (Y)/ Sex
Corneal Lesion
Complication
CDVA
Nucleus Grade
IOL
Intraoperative
Postoperative
FU (Mo)
Retained cortical matter; reaspiration on day 3 Graft infection after 4 wk; controlled with medication d
18
HM
20/80
18
HM
20/60
25
HM
20/40
Preop
Postop
1
59/F
Leucoma (post inflammatory)
4
Foldable
Leaking fluid
2
62/M
Leucoma (post inflammatory)
3
None
3
60/M
2
Foldable
4 5
55/M 63/F
2 2
Foldable Foldable
d d
d d
23 21
CF PL PR(A)
20/40 20/40
6
32M
Leucoma (post inflammatory) Granular dystrophy Salzman nodular degeneration Keratoconus
PC rupture, anterior vitrectomy d
Foldable
d
d
18
PL PR(A)
20/60
7
56/M
Total cataract 3
Foldable
d
d
18
HM
20/30
8
58/M
3
Foldable
d
d
16
HM
20/60
9
60/M
3
Foldable
d
d
18
HM
20/40
10 11
59/M 63/F
3 2
Foldable Foldable
d d
d d
23 21
CF PL PR(A)
20/40 20/30
12
59/M
2
Foldable
d
d
16
HM
20/40
13
59/F
4
Foldable
d
18
HM
4/60*
14
62/M
Leucoma (post inflammatory)
4
Foldable
Pseudomonas infection 1 d postop; controlled with intensive med therapy d
19
HM
20/60
15
60/M
4
Foldable
Corneal edema
18
HM
20/60
16 17
55/M 60/F
2 3
Foldable Foldable
d d
d d
17 21
CF PL PR(A)
20/40 20/40
18
63/F
2
Foldable
d
d
12
HM
20/60
19
62/M
3
Foldable
d
HM
20/60
55/M
3
Foldable
d
Posterior opacity persisted Retained lens matter aspirated at 2 day; corneal edema
19
20
Leucoma (post inflammatory) Granular dystrophy Salzman nodular degeneration Leucoma (post inflammatory) Leucoma (post inflammatory) Corneal ectasia with opacity
18
HM
20/40
Corneal ectasia with opacity Leucoma (post inflammatory) Leucoma (post inflammatory) Granular dystrophy Salzman nodular degeneration Corneal ectasia with opacity Leucoma (post inflammatory)
PC rupture; rigid lens on AC d
AC Z anterior capsule; CDVA Z corrected distance visual acuity; CF Z counting fingers; FU Z follow up; HM Z hand movements; IOL Z intraocular lens; medZ medical therapy; PC Z posterior capsule; PL PR(A) Z perception of light positive and projection of rays accurate
because of the hindered view of the posterior capsule and the positive vitreous pressure. On the other hand, deep lamellar keratoplasty enables the surgeon to perform simultaneous phacoemulsification in a relatively easy manner.9,10 The procedure also provides a clear view of the
anterior chamber from the first postoperative day. Because, unlike PKP, DALK is an extraocular procedure, it is not associated with a risk for graft rejection or post-keratoplasty glaucoma, the 2 important factors in future graft survival. It has a lower risk for suture-related problems because
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
DALK AND PHACOEMULSIFICATION
Figure 1. Bar diagram of postoperative visual acuity (CDVA Z corrected distance visual acuity).
fewer sutures are used and the sutures do not have direct contact with the anterior chamber. The DALK procedure does not cause additional insult to the corneal endothelium.11 Recently, Lee et al.12 advocated the use of a femtosecond laser to refine the DALK technique and increase its precision. Although DALK is often used in challenging cases, several studies13–15 report that surgeons are able to perform the procedure with relative ease while providing the best outcomes for the patient. Thus, the interest in current DALK techniques has grown not only among corneal surgeons but among cataract surgeons as well.9,10,12 However, the current technique has several factors that are essential to its success. They are as follows: (1) The recipient bed should not be larger than 7.5 mm. (2) The eccentricity of the trephine mark must be minimal to allow adequate room for the creation of a clear corneal tunnel.16 (3) The corneal tunnel should be at maximal clear corneal area. (4) High-viscosity OVD should be placed over the recipient Descemet membrane during phacoemulsification. (5) The capsulorhexis should be assisted with capsule staining with dye.17 (6) Low vacuum and a low flow rate must be maintained. (7) Phacoemulsification must be performed using a divide-and-conquer technique. Low aspiration and flow rates avoid the risk for sudden collapse of the anterior chamber and minimize turbulence in the anterior chamber. They also help prevent the media from becoming hazy as a result of Descemet membrane overstretching during the procedure. Anterior capsule staining facilitates visualization of the anterior capsule throughout the procedure and thus assists during various steps. Several recent studies11–13 report that the modified triple procedure in a closed system is effective in eliminating the inherent risks of PKP. Although one may question whether Descemet membrane will be
125
resilient during the phacoemulsification procedure, the membrane is a condensation of collagen IV and laminin that is 7 mm to 10 mm thick. The membrane is quite tough and resistant to the enzymatic degradation that has been observed as descemetocele after total dissolution of the corneal stroma. The results in a study by Muraine et al.10 and our experience show that Descemet membrane can withstand intraoperative intraocular pressure exerted during phacoemulsification. At the end of phacoemulsification and IOL implantation, the self-sealing corneoscleral tunnel permits a firm globe and does not interfere with graft placement and suturing. Because both procedures require similar medications, no extra drugs are required. Furthermore, unlike PKP, the technique is not associated with the risk for postoperative globe rupture. Although ours was a small series, we noted that the technique might not be suitable for grade IV cataract. In conclusion, corneal aberration can be managed using a modified triple procedure comprising DALK with phacoemulsification and foldable IOL implantation in eyes with a nucleus up to grade III. In addition to permitting surgery under the closed chamber system of modern phacoemulsification surgery, the modified triple procedure maintains globe integrity postoperatively, does not add extra insult to the recipient corneal endothelium, and eliminates the inherent risks of PKP. Thus, we recommend that simultaneous DALK with phacoemulsification and IOL insertion be the procedure of choice in eyes with cataract and coexisting corneal opacity. However, the surgeon should be very experienced in performing DALK surgery. REFERENCES 1. Binder PS. Secondary intraocular lens implantation during or after corneal transplantation. Am J Ophthalmol 1985; 99:515–520 2. Panda A, Kumar TS. Keratoplasty and cataract extraction. Indian J Ophthalmol 1991; 39:102–104. Available at: http://www.ijo.in/ text.asp?1991/39/3/102/24461. Accessed August 27, 2010 E. Closed3. Malbran ES, Malbran E, Buonsanti J, Adroque system phacoemulsification and posterior chamber implant combined with penetrating keratoplasty. Ophthalmic Surg 1993; 24:403–406 4. Baca LS, Epstein RJ. Closed-chamber capsulorhexis for cataract extraction combined with penetrating keratoplasty. J Cataract Refract Surg 1998; 24:581–584 5. Caporossi A, Traversi C, Simi C, Tosi GM. Closed-system and open-sky capsulorhexis for combined cataract extraction and corneal transplantation. J Cataract Refract Surg 2001; 27:990–993 6. Nardi M, Giudice V, Marabotti A, Alfieri E, Rizzo S. Temporary graft for closed-system cataract surgery during corneal triple procedures. J Cataract Refract Surg 2001; 27:1172–1175 7. Menapace R, Skorpik C, Grasl M. Modified triple procedure using a temporary keratoprosthesis for closed-system, small-incision cataract surgery. J Cataract Refract Surg 1990; 16:230–234 8. Panda A, Singh R. Intralamellar dissection techniques in lamellar keratoplasty. Cornea 2000; 19:22–25; errata, 765
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
126
DALK AND PHACOEMULSIFICATION
9. Senoo T. Combined surgery with deep lamellar keratoplasty. Semin Ophthalmol 2001; 16:126–136 10. Muraine MC, Collet A, Brasseur G. Deep lamellar keratoplasty combined with cataract surgery. Arch Ophthalmol 2002; 120:812–815 11. Morris E, Kirwan JF, Sujatha S, Rostron CK. Corneal endothelial specular microscopy following deep lamellar keratoplasty with lyophilised tissue. Eye 1998; 12:619–622 12. Lee D, Kim J-H, Oh S-H, Choi S-K, Kim JK. Femtosecond laser lamellar keratoplasty to aid visualization for cataract surgery. J Refract Surg 2009; 25:902–904 13. Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol 1997; 81:184–188. Available at: http://www.ncbi. nlm.nih.gov/pmc/articles/PMC1722147/pdf/v081p00184.pdf. Accessed August 27, 2010 14. Panda A, Singh Bageshwar LM, Ray M, Singh JP, Kumar A. Deep lamellar keratoplasty versus penetrating keratoplasty for corneal lesions. Cornea 1999; 18:172–175
15. Terry MA. The evolution of lamellar grafting technique over twenty-five years. Cornea 2000; 19:611–616 16. Baykara M, Uc‚an G. Modifying the position of cataract incisions in triple procedure. Eur J Ophthalmol 2008; 18: 891–894 17. Kobayashi A, Segawa Y, Nishimura A, Shirao Y, Sugiyama K. Indocyanine green staining for the triple corneal procedure. Ophthalmic Surg Lasers Imaging 2004; 35:23–25
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
First author: Anita Panda, MD, FAMS, FICS, FICO, MRCOphth Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Deep anterior lamellar keratoplasty with phacoemulsification Anita Panda, MD, FAMS, FICS, FICO, MRCOphth, Harinder Singh Sethi, MD, Mohit Jain, MD, Sasikala Nindra Krishna, DOMS, Anoop Kishore Gupta, MD
PURPOSE: To evaluate the technique and outcomes of deep anterior lamellar keratoplasty (DALK) combined with phacoemulsification for corneal opacity with coexisting cataract. SETTING: Cornea Service, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: Cohort study. METHODS: Eyes with cataract of varied nucleus grade and with different corneal pathologies were selected. Modified triple procedures were performed in all eyes. RESULTS: Twenty eyes were evaluated. The corrected distance visual acuity (CDVA) after 3 months was 20/60 or better in 18 eyes. One eye had 20/80 CDVA as a result of perioperative and postoperative complications. One graft became opaque after postoperative infection. CONCLUSION: Simultaneous DALK with phacoemulsification was feasible in eyes with coexisting corneal and lenticular pathology, and the outcomes were encouraging. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:122–126 Q 2011 ASCRS and ESCRS
Phacoemulsification is considered a modern cataract surgical procedure worldwide. However, the surgeon requires a very clear view during surgery, and this can be hindered by the presence of corneal opacities of any depth. In eyes with cataract and coexisting corneal opacity, there are 2 options. The first is penetrating keratoplasty (PKP) followed by cataract surgery at a later date (2-stage procedure).1 This option provides delayed rehabilitation to the patient and risks endothelial stress. The second option is simultaneous PKP with cataract extraction and intraocular lens (IOL) insertion (triple procedure).2 The triple procedure has several benefits over the 2-stage technique. These include
Submitted: June 19, 2010. Final revision submitted: July 13, 2010. Accepted: July 14, 2010. From Dr. Rajendra Prasad Centre for Ophthalmic Sciences (Panda, Jain, Nindra Krishna, Gupta), All India Institute of Medical Sciences, and Sufdarjung Hospital (Sethi), New Delhi, India. Corresponding author: Anita Panda, MD, D-II/33, Ansari Nagar, New Delhi–110029, India. E-mail: [email protected].
122
Q 2011 ASCRS and ESCRS Published by Elsevier Inc.
a shorter period of visual disability, an overall reduction in the length of the hospital stay, and fewer follow-up visits; thus, the triple procedure is less of a financial burden to the patient. However, a conventional simultaneous triple procedure, although popular, has limitations as well. For example, it is not possible to perform phacoemulsification because of the open-sky recipient window, there is a high risk for radial capsule tear during capsulorhexis, the inherent positive vitreous pressure is cumbersome to the surgeon, there is a greater risk for posterior capsule dehiscence, and cortical cleaning may be inadequate. To obviate these inherent problems of a conventional triple procedure, phacoemulsification is advocated after the corneal opacity is debulked in the anterior corneal lesion,3–5 a temporary corneal graft is placed,6 or keratoprosthesis7 is used during surgery. All 3 options have limitations. We perform a simultaneous triple procedure that varies from the conventional technique in 2 ways. First, we perform deep lamellar keratoplasty (DALK) instead of PKP. Second, we perform phacoemulsification with IOL implantation instead of conventional extracapsular lens extraction. 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2010.07.031
DALK AND PHACOEMULSIFICATION
PATIENTS AND METHODS Patients with deep central corneal lesions and cataract were recruited from the Cornea Clinic, Dr. Rajendra Prasad Centre for Ophthalmic Science, All India Institute of Medical Sciences, New Delhi, India, a tertiary eyecare center. The presence of light projection and accurate perception of rays in all quadrants was a prerequisite in all cases. All eyes were evaluated by ultrasonography and electrophysiologic examination. A detailed slitlamp examination was performed to elucidate the tear meniscus; nature of the vascularization, if any; and depth of corneal lesion invading the posterior stroma. Eyes with tear-film abnormality, stem-cell deficiency, or posterior segment abnormalities were excluded.
Surgical Technique The senior surgeon (A.P.) performed all procedures using peribulbar anesthesia. All surgeries were on an elective basis.
Recipient Bed Preparation To prepare the recipient bed, a 0.4 mm deep mark was made with a 7.5 mm trephine. The mark was slightly eccentric to allow adequate space for the clear corneal tunnel. The anterior lamellar button was removed manually with the help of a lamellar corneal dissector, as previously described.8 Care was taken not to pierce through Descemet membrane. Any remnant of posterior stromal lamellae was removed with caution to achieve a fully transparent Descemet membrane. A high-viscosity ophthalmic viscosurgical device (OVD) was placed over the recipient corneal bed. At no time was saline used to clean the operating field. The operating field was kept dry using a polyvinyl alcohol sponge (Merocel). Phacoemulsification and Intraocular Lens Insertion
Sideport incisions were made at 2 o’clock and 10 o’clock with a microvitreoretinal knife to allow future manipulation. With a 2.7 mm keratome, a clear corneal tunnel was made at the superior cornea (the area at which the maximum recipient clear cornea was available). The anterior capsule was stained with trypan blue injected under the air bubble. The anterior chamber was washed with a balanced salt solution. The OVD was injected into the anterior chamber and the capsulorhexis completed. Complete hydrodissection was performed in the conventional manner. Phacoemulsification was completed by a divide-and-conquer technique. Low vacuum and low flow rates were used throughout the procedure. Complete cortical aspiration was performed using a low aspiration rate. The capsular bag was inflated with OVD and a foldable IOL inserted. The corneal tunnel and side port were hydrated.
Donor Tissue Preparation and Suturing A 7.75 mm donor corneal button was punched from the endothelial side from B-grade McCarey-Kaufman preserved corneal donor tissue. The endothelium was scrapped completely from the button. The recipient bed was rinsed with a saline sponge to remove the OVD, tissue debris, or foreign bodies. The donor button was sutured to the recipient bed with 12-16 monofilament 10-0 nylon sutures with buried knots. A subconjunctival injection of 4 mg dexamethasone and 20 mg gentamicin was given at the end of surgery.
Postoperative Protocol All eyes received topical corticosteroid agents, antibiotic agents, and surface lubricants postoperatively, which were
123
gradually tapered. Patients were followed regularly after discharge as follows: weekly for 2 weeks, once during the next 15 days, once a month for 2 months, and every 3 months thereafter. Graft clarity, anterior chamber status, corneal topography, and specular microscopy were recorded at each visit.
RESULTS The study enrolled 20 eyes of 20 patients. The mean age of the patients was 58.1 years G 6.6878 (SD) (range 55 to 63 years). Table 1 shows the preoperative and postoperative data. In 1 eye, in which the trephine mark was central for a short clear corneal tunnel, fluid leaked from the anterior chamber during maneuvering, which increased recipient corneal hydration and thus hindered visibility. In 2 cases there was posterior capsule rupture; 1 case required anterior vitrectomy and was left aphakic and in the other, a rigid IOL was implanted over the anterior capsule. There were no other intraoperative complications. Although the corneal and the anterior chamber view were not very good at the end of surgery, both were sufficiently clear to allow the graft status and anterior chamber details to be monitored from the first postoperative day onward. All but 1 eye achieved a good visual outcome at the end of 12 weeks (Figure 1). One eye had retained cortical lens matter and had reaspiration of the material 3 days postoperatively. No eye developed postkeratoplasty glaucoma or rejection. DISCUSSION With the invention of modern small-incision sutureless cataract surgery, the popularity of large-incision surgical techniques, such as intracapsular or extracapsular cataract extraction, is fading. Nevertheless, cataract with coexisting corneal opacity of any depth and size is cumbersome to the cataract surgeon during surgery because it hinders visibility. Furthermore, postoperative visual rehabilitation is challenging. Two conventional techniques to manage these cases are available. The first is a 2-stage technique1 in which PKP is followed by cataract surgery at a later date. The second option is simultaneous PKP, cataract extraction, and IOL insertion (triple procedure).2 The former is associated with delayed optical rehabilitation, endothelial stress, and a risk for graft rejection. The triple procedure, thus, is more popular in these cases. However, the modern cataract surgical technique of phacoemulsification is not feasible during this procedure because of the open-sky recipient window. Furthermore, there is a greater chance of posterior capsular tear from positive vitreous pressure and complete aspiration of the cortical matter may not be possible
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
124
DALK AND PHACOEMULSIFICATION
Table 1. Preoperative and postoperative patient data.
Pt
Age (Y)/ Sex
Corneal Lesion
Complication
CDVA
Nucleus Grade
IOL
Intraoperative
Postoperative
FU (Mo)
Retained cortical matter; reaspiration on day 3 Graft infection after 4 wk; controlled with medication d
18
HM
20/80
18
HM
20/60
25
HM
20/40
Preop
Postop
1
59/F
Leucoma (post inflammatory)
4
Foldable
Leaking fluid
2
62/M
Leucoma (post inflammatory)
3
None
3
60/M
2
Foldable
4 5
55/M 63/F
2 2
Foldable Foldable
d d
d d
23 21
CF PL PR(A)
20/40 20/40
6
32M
Leucoma (post inflammatory) Granular dystrophy Salzman nodular degeneration Keratoconus
PC rupture, anterior vitrectomy d
Foldable
d
d
18
PL PR(A)
20/60
7
56/M
Total cataract 3
Foldable
d
d
18
HM
20/30
8
58/M
3
Foldable
d
d
16
HM
20/60
9
60/M
3
Foldable
d
d
18
HM
20/40
10 11
59/M 63/F
3 2
Foldable Foldable
d d
d d
23 21
CF PL PR(A)
20/40 20/30
12
59/M
2
Foldable
d
d
16
HM
20/40
13
59/F
4
Foldable
d
18
HM
4/60*
14
62/M
Leucoma (post inflammatory)
4
Foldable
Pseudomonas infection 1 d postop; controlled with intensive med therapy d
19
HM
20/60
15
60/M
4
Foldable
Corneal edema
18
HM
20/60
16 17
55/M 60/F
2 3
Foldable Foldable
d d
d d
17 21
CF PL PR(A)
20/40 20/40
18
63/F
2
Foldable
d
d
12
HM
20/60
19
62/M
3
Foldable
d
HM
20/60
55/M
3
Foldable
d
Posterior opacity persisted Retained lens matter aspirated at 2 day; corneal edema
19
20
Leucoma (post inflammatory) Granular dystrophy Salzman nodular degeneration Leucoma (post inflammatory) Leucoma (post inflammatory) Corneal ectasia with opacity
18
HM
20/40
Corneal ectasia with opacity Leucoma (post inflammatory) Leucoma (post inflammatory) Granular dystrophy Salzman nodular degeneration Corneal ectasia with opacity Leucoma (post inflammatory)
PC rupture; rigid lens on AC d
AC Z anterior capsule; CDVA Z corrected distance visual acuity; CF Z counting fingers; FU Z follow up; HM Z hand movements; IOL Z intraocular lens; medZ medical therapy; PC Z posterior capsule; PL PR(A) Z perception of light positive and projection of rays accurate
because of the hindered view of the posterior capsule and the positive vitreous pressure. On the other hand, deep lamellar keratoplasty enables the surgeon to perform simultaneous phacoemulsification in a relatively easy manner.9,10 The procedure also provides a clear view of the
anterior chamber from the first postoperative day. Because, unlike PKP, DALK is an extraocular procedure, it is not associated with a risk for graft rejection or post-keratoplasty glaucoma, the 2 important factors in future graft survival. It has a lower risk for suture-related problems because
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
DALK AND PHACOEMULSIFICATION
Figure 1. Bar diagram of postoperative visual acuity (CDVA Z corrected distance visual acuity).
fewer sutures are used and the sutures do not have direct contact with the anterior chamber. The DALK procedure does not cause additional insult to the corneal endothelium.11 Recently, Lee et al.12 advocated the use of a femtosecond laser to refine the DALK technique and increase its precision. Although DALK is often used in challenging cases, several studies13–15 report that surgeons are able to perform the procedure with relative ease while providing the best outcomes for the patient. Thus, the interest in current DALK techniques has grown not only among corneal surgeons but among cataract surgeons as well.9,10,12 However, the current technique has several factors that are essential to its success. They are as follows: (1) The recipient bed should not be larger than 7.5 mm. (2) The eccentricity of the trephine mark must be minimal to allow adequate room for the creation of a clear corneal tunnel.16 (3) The corneal tunnel should be at maximal clear corneal area. (4) High-viscosity OVD should be placed over the recipient Descemet membrane during phacoemulsification. (5) The capsulorhexis should be assisted with capsule staining with dye.17 (6) Low vacuum and a low flow rate must be maintained. (7) Phacoemulsification must be performed using a divide-and-conquer technique. Low aspiration and flow rates avoid the risk for sudden collapse of the anterior chamber and minimize turbulence in the anterior chamber. They also help prevent the media from becoming hazy as a result of Descemet membrane overstretching during the procedure. Anterior capsule staining facilitates visualization of the anterior capsule throughout the procedure and thus assists during various steps. Several recent studies11–13 report that the modified triple procedure in a closed system is effective in eliminating the inherent risks of PKP. Although one may question whether Descemet membrane will be
125
resilient during the phacoemulsification procedure, the membrane is a condensation of collagen IV and laminin that is 7 mm to 10 mm thick. The membrane is quite tough and resistant to the enzymatic degradation that has been observed as descemetocele after total dissolution of the corneal stroma. The results in a study by Muraine et al.10 and our experience show that Descemet membrane can withstand intraoperative intraocular pressure exerted during phacoemulsification. At the end of phacoemulsification and IOL implantation, the self-sealing corneoscleral tunnel permits a firm globe and does not interfere with graft placement and suturing. Because both procedures require similar medications, no extra drugs are required. Furthermore, unlike PKP, the technique is not associated with the risk for postoperative globe rupture. Although ours was a small series, we noted that the technique might not be suitable for grade IV cataract. In conclusion, corneal aberration can be managed using a modified triple procedure comprising DALK with phacoemulsification and foldable IOL implantation in eyes with a nucleus up to grade III. In addition to permitting surgery under the closed chamber system of modern phacoemulsification surgery, the modified triple procedure maintains globe integrity postoperatively, does not add extra insult to the recipient corneal endothelium, and eliminates the inherent risks of PKP. Thus, we recommend that simultaneous DALK with phacoemulsification and IOL insertion be the procedure of choice in eyes with cataract and coexisting corneal opacity. However, the surgeon should be very experienced in performing DALK surgery. REFERENCES 1. Binder PS. Secondary intraocular lens implantation during or after corneal transplantation. Am J Ophthalmol 1985; 99:515–520 2. Panda A, Kumar TS. Keratoplasty and cataract extraction. Indian J Ophthalmol 1991; 39:102–104. Available at: http://www.ijo.in/ text.asp?1991/39/3/102/24461. Accessed August 27, 2010 E. Closed3. Malbran ES, Malbran E, Buonsanti J, Adroque system phacoemulsification and posterior chamber implant combined with penetrating keratoplasty. Ophthalmic Surg 1993; 24:403–406 4. Baca LS, Epstein RJ. Closed-chamber capsulorhexis for cataract extraction combined with penetrating keratoplasty. J Cataract Refract Surg 1998; 24:581–584 5. Caporossi A, Traversi C, Simi C, Tosi GM. Closed-system and open-sky capsulorhexis for combined cataract extraction and corneal transplantation. J Cataract Refract Surg 2001; 27:990–993 6. Nardi M, Giudice V, Marabotti A, Alfieri E, Rizzo S. Temporary graft for closed-system cataract surgery during corneal triple procedures. J Cataract Refract Surg 2001; 27:1172–1175 7. Menapace R, Skorpik C, Grasl M. Modified triple procedure using a temporary keratoprosthesis for closed-system, small-incision cataract surgery. J Cataract Refract Surg 1990; 16:230–234 8. Panda A, Singh R. Intralamellar dissection techniques in lamellar keratoplasty. Cornea 2000; 19:22–25; errata, 765
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
126
DALK AND PHACOEMULSIFICATION
9. Senoo T. Combined surgery with deep lamellar keratoplasty. Semin Ophthalmol 2001; 16:126–136 10. Muraine MC, Collet A, Brasseur G. Deep lamellar keratoplasty combined with cataract surgery. Arch Ophthalmol 2002; 120:812–815 11. Morris E, Kirwan JF, Sujatha S, Rostron CK. Corneal endothelial specular microscopy following deep lamellar keratoplasty with lyophilised tissue. Eye 1998; 12:619–622 12. Lee D, Kim J-H, Oh S-H, Choi S-K, Kim JK. Femtosecond laser lamellar keratoplasty to aid visualization for cataract surgery. J Refract Surg 2009; 25:902–904 13. Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol 1997; 81:184–188. Available at: http://www.ncbi. nlm.nih.gov/pmc/articles/PMC1722147/pdf/v081p00184.pdf. Accessed August 27, 2010 14. Panda A, Singh Bageshwar LM, Ray M, Singh JP, Kumar A. Deep lamellar keratoplasty versus penetrating keratoplasty for corneal lesions. Cornea 1999; 18:172–175
15. Terry MA. The evolution of lamellar grafting technique over twenty-five years. Cornea 2000; 19:611–616 16. Baykara M, Uc‚an G. Modifying the position of cataract incisions in triple procedure. Eur J Ophthalmol 2008; 18: 891–894 17. Kobayashi A, Segawa Y, Nishimura A, Shirao Y, Sugiyama K. Indocyanine green staining for the triple corneal procedure. Ophthalmic Surg Lasers Imaging 2004; 35:23–25
J CATARACT REFRACT SURG - VOL 37, JANUARY 2011
First author: Anita Panda, MD, FAMS, FICS, FICO, MRCOphth Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India