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The triple procedure: combined penetrating keratoplasty, cataract extraction and lens implantation
the triple procedure: combined penetrating keratoplasty, cataract extraction and lens implantation John D. Hunkeler, M.D. L.L. Hyde, M.D. Kansas City, Missouri
Until the late 1960's patients with combined cataract and corneal disease requiring surgery were advised to have nonsimultaneous keratoplasty and cataract extraction. In 1966, Katzin l reported 70% success with simultaneous keratoplasty and cataract extraction. Casey2 reported similar success in 1969. Kaufman 3 also recommended removal of an opacifying lens during keratoplasty, stating that the lens would otherwise become more cloudy. Simultaneous cataract extraction and keratoplasty avoided the graft loss associated with cataract extraction performed several months after keratoplasty.4.5 In 1974, Kaufman 6 reported identical results for keratoplasty with or without simultaneous cataract extraction in cases of bullous keratopathy. In 1976, Troutman 7 reported 90% clear grafts for corr.bined keratoplasty and cataract extraction, compared to only 70% clear grafts when cataract surgery was done at a later date. HydeS reported that the posterior capsule could be left intact during simultaneous cataract extraction and keratoplasty by utilizing microsurgical extracapsular cataract extraction. Although this technique demanded removal of all residual lens rortex, the remaining intact posterior capsule definitely. protected the corneal endothelium from prolapsing vitreous and eliminated the frequent need for vitrectomy. This technique was also associated with fewer macular, peripheral retinal and glaucoma problems. Polack9 also reported favorable results for combined extracapsular cataract extraction and keratoplasty. While these advances were occurring in combined keratoplasty and cataract surgery, increasing attention was being focused on the visual rehabilitation of aphakia using intraocular lens (IOL) implants. It was logical to consider pseudophakia as part of a triple procedure for patients with combined corneal and cataract disease. In fact, using the triple procedure of intracapsular cataract extraction, keratoplasty and lens implantation, Taylor lo.ll reported 90% dear grafts in a series of 11 cases, with 40% of the
Presented at the U.S. IOL Symposium in Los Angeles, April 1979.
222
patients achieving visual acuities of 20/40 or better. Lee and Dohlman,l2 Alparl3 and Buxton l4 also reported favorably on the use of a triple procedure. This study reports the results obtained for a series of 60 patients undergoing combined penetrating keratoplasty, microsurgical extracapsular cataract extraction and intraocular lens implantation.
MATERIALS AND METHODS A consecutive series of 67 triple procedures was begun in 1973 and continued through April 1978. The age range of the patients was 51 to 93, with a mean age of 73. There were 47 female patients and 13 male patients. Seven patients had bilateral surgery. Sixty eyes were diagnosed preoperatively with Fuchs's dystrophy and cataract; six had corneal scarring; one had keratoconus. The surgical procedure was performed with either local anesthesia (58%) or general anesthesia. A soft eye was obtained with massage or a soft rubber ball.I 5 The pupil was dilated and the host cornea excised using a disposable trephine. The donor cornea was prepared in standard fashion, either by dissection or by cutting it on a Teflon block with a corneal punch. Twenty-one percent of the cases received McCarey-Kaufman prepared corneas. 16 The most common graft size was 8.0 mm in diameter (used in 80% of the eyes), although graft sizes of 7.0, 7.5, and 8.5 mm were also used. The host cornea was removed and a "circle/lazy H" was cut in the anterior lens capsule to create flaps for the IOL loops. The lens nucleus was loosened and removed. Remaining lens cortex and capsular tags were aspirated, the posterior capsule was polished and a 10-0 Prolene (polypropylene) iris suture was then placed at 12 o'clock. The IOL was sutured to the iris and placed in the capsular bag before the pupil was constricted with acetylcholine. Two iridectomies were performed and the corneal graft sutured in place with an air bubble over the implant. IOLs implanted included four 2-100p iridocapsular lenses, 17 medallion-style iris suture lenses, and 46 iris suture lenses. Lens powers ranged from + 18.00 to +20.00 diopters; 38% of the lenses used were +20.00 diopters. RESULTS At follow-up times ranging from 12 to 66 months (mean 23 months) postoperatively, 72% of the eyes had visual acuities of 20/40 or better (Table 1). Eleven eyes experienced visual loss from either senile
AM INTRA·OCULAR IMPLANT SOC J-VOL. v, JULY 1979
macular degeneration (seven cases), optic atrophy (one case), amblyopia (two cases) or cystoid macular edema (one case). Thirty-two percent of the cases required a discission from three to 40 months post-op (mean 16 months). Table I. Post-op visual acuities for patients undergoing triple procedure.
Visual Acuity
Number of Eyes
20/20
4 (6.1%)
20/25
22 (32.8%)
20/30
12 (17.9%)
20/40
IO (14.9%)
20/50-20/100 :(20/200
9 (13.4%) 10 (14.9%) 67 (100%)
There have been no retinal detachments in this senes. There were four cases of glaucoma: two were mild and well-controlled preoperatively and two were new cases. All four cases are now controlled by medication. Perhaps because of the absence of pseudophakodonesis and because of the continued use of moderate doses of topical steroids, iritis has not been a problem in this series. Secure capsular fixation of the IOL prevents pseudophakodonesis and contact between the IOL and endothelium. Usually capsular fixation was secure enough to allow pupillary dilatation at the fourth post-op day. Only one patient's IOL failed to achieve capsular fixation and that patient has only minimal pseudophakodonesis. Clear grafts were obtained in 66 eyes. The one cloudy graft was successfully regrafted, leaving the IOL in place. Two other grafts are now failing. In one of these cases, the patient had left the operating room with a slightly frayed area in the 10-0 nylon suture which ruptured one week postoperatively. Although the wound dehiscence was repaired promptly, the endothelial cell count is now 372 cells/mm 2 • The second case appears to be a graft rejection. Intraoperative complications were minimal: one case of intraoperative capsule rupture was accompanied by vitreous loss, and an Ocutome vitrectomy was subsequently performed. In another case, the peripheral iridectomies were forgotten and a peripheral iridectomy had to be done one-day postop to treat pupillary block.
Using the Heyer-Schulte clinical specular photomicroscope, endothelial cell pictures were taken over a period of nine to 66 months post-op, with an average time of 21 months post-op. Of the 25 eyes with countable specular pictures, the mean endothelial cell count was 1416 cells/mm 2, with a range of 372 to 1984 cells/mm 2• Two eyes with cell counts less than 500 were those mentioned above in which the graft appeared to be failing. According to Hoffer,17 a cell count of 370 is close to endothelial decompensation: 25 of these 27 eyes had cell counts of at least 750 cells/mm 2 . DISCUSSION The triple procedure can be performed with excellent results using extracapsular microsurgical cataract techniques. The extracapsular technique allows the posterior capsule to remain as a barrier between aqueous and vitreous, reducing the risk of post-op endothelial or retinal complications. The posterior capsule also offers a stable fixation platform for an IOL.18 The complication rates with this procedure are low initially and remain low. The stable pseudophakos-capsule-iris diaphragm keeps the IOL firmly centered and well away from the cornea. Consequently, there is no irritation from pseudophakodonesis, no intermittent c()rneal touch and good visual results (Fig. 1).
Fig. I (Hunkeler and Hyde). Twelve-month post-op view of eye after extracapsular cataract extraction, keratoplasty and lens implantation.
SUMMARY Results of combined keratoplasty, extracapsular cataract extraction and lens implantation (triple
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JULY 1979
223
procedure) are reported for 67 eyes having at least 12 months follow-up. The average age of the patients was 73; the majority were female with a pre-op diagnosis of Fuchs's dystrophy. Post-op visual acuities were 20/ 40 or better in 72% of the eyes. No implants were removed and only one eye required regrafting. The discission rate was 32%; discissions were usually performed a year post-op. We feel the favorable results are due to uniform use of microsurgical extracapsular cataract extraction at the time of surgery with good capsular fixation of the lens implant. REFERENCES I. Katzin HM: Combined surgery for corneal transplantation and cataract extraction. Am] Ophthalmol 62:556, 1966
2. Casey T A: The combined operation of cataract and corneal graft. Trans Ophthalmol Soc UK 89:659, 1969
3. Kaufman HE: Combined graft and cataract extraction, in Welsh R (ed): Cataract Surgery. Miami Educational Press, 1969, p 192 4. Buxton J: Non-simultaneous and simultaneous corneal graft and cataract extraction, in Welsh R (ed): Cataract Surgery. Miami Educational Press, 1969, p 196 5. Lemp MA, Pfister RR, Dohlmann CH: The effect of intraocular surgery on clear corneal grafts. Am ] Ophthalmol 77:824, 1974 6. Kaufman HE: Combined keratoplasty and cataract extraction. Am] Ophthalmol 77:824, 1974
7. Troutman E: Aphakic and combined grafts, in Emery J (ed): Current Concepts of Cataract Surgery: Selected Proceedings of the Fourth Biennial Cataract Surgical Congress. St. Louis, CVMosby Co, 1976, p 160
8. Hyde LL: Extracapsular cataract extraction combined with corneal grafting, in Emery J (ed): Current Concepts of Cataract Surgery: Selected Proceedings of the Fourth Biennial Cataract Surgical Congress. SI. Louis, CV Mosby Co, 1976, P 162 , 9. Polack FM: Corneal Transplantation. Grune and Stratton, 1978, p 158 10. Taylor DM: Keratoplasty and intraocular lenses. OphthalmIc Surg 7(1):31, 1976 II. Taylor DM: Keratoplasiy and intraocular lenses; follow-up study. Ophthalmic SUTg 8(2):49, 1977 12. Lee JR, Dohlman C: Intraocular lens implantation in combination with keratoplasty. Annals Ophthalmol9:513, 1977 13. Alpar 11: Keratoplasty with primary and secondary lens implantations. Ophthalmic Surg 9:59, 1978 14. Buxton IN, Jaffe MS: Combined keratoplasty, cataract extraction with intraocular lens implantation. Am IntraOcular Imp Soc] 4: 110, 1978 15. Gills JP: Constant mild compression of the eye to produce hypotension. Am Intra-Ocular Imp Soc] 5:52, 1979 16. McCarey BE, Kaufman HE: Improved corneal storage. Invest Ophthalmol 13: 165, 1974 17. Hoffer KJ: Corneal decompensation after corneal endothethelium cell count. Am ] Ophthalmol 84:252, 1978 18. Worst JGF: Extracapsular surgery in lens implantation. Am Intra-Ocular Imp Soc] 4(1) :7, 1978
224
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JULY 1979
Until the late 1960's patients with combined cataract and corneal disease requiring surgery were advised to have nonsimultaneous keratoplasty and cataract extraction. In 1966, Katzin l reported 70% success with simultaneous keratoplasty and cataract extraction. Casey2 reported similar success in 1969. Kaufman 3 also recommended removal of an opacifying lens during keratoplasty, stating that the lens would otherwise become more cloudy. Simultaneous cataract extraction and keratoplasty avoided the graft loss associated with cataract extraction performed several months after keratoplasty.4.5 In 1974, Kaufman 6 reported identical results for keratoplasty with or without simultaneous cataract extraction in cases of bullous keratopathy. In 1976, Troutman 7 reported 90% clear grafts for corr.bined keratoplasty and cataract extraction, compared to only 70% clear grafts when cataract surgery was done at a later date. HydeS reported that the posterior capsule could be left intact during simultaneous cataract extraction and keratoplasty by utilizing microsurgical extracapsular cataract extraction. Although this technique demanded removal of all residual lens rortex, the remaining intact posterior capsule definitely. protected the corneal endothelium from prolapsing vitreous and eliminated the frequent need for vitrectomy. This technique was also associated with fewer macular, peripheral retinal and glaucoma problems. Polack9 also reported favorable results for combined extracapsular cataract extraction and keratoplasty. While these advances were occurring in combined keratoplasty and cataract surgery, increasing attention was being focused on the visual rehabilitation of aphakia using intraocular lens (IOL) implants. It was logical to consider pseudophakia as part of a triple procedure for patients with combined corneal and cataract disease. In fact, using the triple procedure of intracapsular cataract extraction, keratoplasty and lens implantation, Taylor lo.ll reported 90% dear grafts in a series of 11 cases, with 40% of the
Presented at the U.S. IOL Symposium in Los Angeles, April 1979.
222
patients achieving visual acuities of 20/40 or better. Lee and Dohlman,l2 Alparl3 and Buxton l4 also reported favorably on the use of a triple procedure. This study reports the results obtained for a series of 60 patients undergoing combined penetrating keratoplasty, microsurgical extracapsular cataract extraction and intraocular lens implantation.
MATERIALS AND METHODS A consecutive series of 67 triple procedures was begun in 1973 and continued through April 1978. The age range of the patients was 51 to 93, with a mean age of 73. There were 47 female patients and 13 male patients. Seven patients had bilateral surgery. Sixty eyes were diagnosed preoperatively with Fuchs's dystrophy and cataract; six had corneal scarring; one had keratoconus. The surgical procedure was performed with either local anesthesia (58%) or general anesthesia. A soft eye was obtained with massage or a soft rubber ball.I 5 The pupil was dilated and the host cornea excised using a disposable trephine. The donor cornea was prepared in standard fashion, either by dissection or by cutting it on a Teflon block with a corneal punch. Twenty-one percent of the cases received McCarey-Kaufman prepared corneas. 16 The most common graft size was 8.0 mm in diameter (used in 80% of the eyes), although graft sizes of 7.0, 7.5, and 8.5 mm were also used. The host cornea was removed and a "circle/lazy H" was cut in the anterior lens capsule to create flaps for the IOL loops. The lens nucleus was loosened and removed. Remaining lens cortex and capsular tags were aspirated, the posterior capsule was polished and a 10-0 Prolene (polypropylene) iris suture was then placed at 12 o'clock. The IOL was sutured to the iris and placed in the capsular bag before the pupil was constricted with acetylcholine. Two iridectomies were performed and the corneal graft sutured in place with an air bubble over the implant. IOLs implanted included four 2-100p iridocapsular lenses, 17 medallion-style iris suture lenses, and 46 iris suture lenses. Lens powers ranged from + 18.00 to +20.00 diopters; 38% of the lenses used were +20.00 diopters. RESULTS At follow-up times ranging from 12 to 66 months (mean 23 months) postoperatively, 72% of the eyes had visual acuities of 20/40 or better (Table 1). Eleven eyes experienced visual loss from either senile
AM INTRA·OCULAR IMPLANT SOC J-VOL. v, JULY 1979
macular degeneration (seven cases), optic atrophy (one case), amblyopia (two cases) or cystoid macular edema (one case). Thirty-two percent of the cases required a discission from three to 40 months post-op (mean 16 months). Table I. Post-op visual acuities for patients undergoing triple procedure.
Visual Acuity
Number of Eyes
20/20
4 (6.1%)
20/25
22 (32.8%)
20/30
12 (17.9%)
20/40
IO (14.9%)
20/50-20/100 :(20/200
9 (13.4%) 10 (14.9%) 67 (100%)
There have been no retinal detachments in this senes. There were four cases of glaucoma: two were mild and well-controlled preoperatively and two were new cases. All four cases are now controlled by medication. Perhaps because of the absence of pseudophakodonesis and because of the continued use of moderate doses of topical steroids, iritis has not been a problem in this series. Secure capsular fixation of the IOL prevents pseudophakodonesis and contact between the IOL and endothelium. Usually capsular fixation was secure enough to allow pupillary dilatation at the fourth post-op day. Only one patient's IOL failed to achieve capsular fixation and that patient has only minimal pseudophakodonesis. Clear grafts were obtained in 66 eyes. The one cloudy graft was successfully regrafted, leaving the IOL in place. Two other grafts are now failing. In one of these cases, the patient had left the operating room with a slightly frayed area in the 10-0 nylon suture which ruptured one week postoperatively. Although the wound dehiscence was repaired promptly, the endothelial cell count is now 372 cells/mm 2 • The second case appears to be a graft rejection. Intraoperative complications were minimal: one case of intraoperative capsule rupture was accompanied by vitreous loss, and an Ocutome vitrectomy was subsequently performed. In another case, the peripheral iridectomies were forgotten and a peripheral iridectomy had to be done one-day postop to treat pupillary block.
Using the Heyer-Schulte clinical specular photomicroscope, endothelial cell pictures were taken over a period of nine to 66 months post-op, with an average time of 21 months post-op. Of the 25 eyes with countable specular pictures, the mean endothelial cell count was 1416 cells/mm 2, with a range of 372 to 1984 cells/mm 2• Two eyes with cell counts less than 500 were those mentioned above in which the graft appeared to be failing. According to Hoffer,17 a cell count of 370 is close to endothelial decompensation: 25 of these 27 eyes had cell counts of at least 750 cells/mm 2 . DISCUSSION The triple procedure can be performed with excellent results using extracapsular microsurgical cataract techniques. The extracapsular technique allows the posterior capsule to remain as a barrier between aqueous and vitreous, reducing the risk of post-op endothelial or retinal complications. The posterior capsule also offers a stable fixation platform for an IOL.18 The complication rates with this procedure are low initially and remain low. The stable pseudophakos-capsule-iris diaphragm keeps the IOL firmly centered and well away from the cornea. Consequently, there is no irritation from pseudophakodonesis, no intermittent c()rneal touch and good visual results (Fig. 1).
Fig. I (Hunkeler and Hyde). Twelve-month post-op view of eye after extracapsular cataract extraction, keratoplasty and lens implantation.
SUMMARY Results of combined keratoplasty, extracapsular cataract extraction and lens implantation (triple
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JULY 1979
223
procedure) are reported for 67 eyes having at least 12 months follow-up. The average age of the patients was 73; the majority were female with a pre-op diagnosis of Fuchs's dystrophy. Post-op visual acuities were 20/ 40 or better in 72% of the eyes. No implants were removed and only one eye required regrafting. The discission rate was 32%; discissions were usually performed a year post-op. We feel the favorable results are due to uniform use of microsurgical extracapsular cataract extraction at the time of surgery with good capsular fixation of the lens implant. REFERENCES I. Katzin HM: Combined surgery for corneal transplantation and cataract extraction. Am] Ophthalmol 62:556, 1966
2. Casey T A: The combined operation of cataract and corneal graft. Trans Ophthalmol Soc UK 89:659, 1969
3. Kaufman HE: Combined graft and cataract extraction, in Welsh R (ed): Cataract Surgery. Miami Educational Press, 1969, p 192 4. Buxton J: Non-simultaneous and simultaneous corneal graft and cataract extraction, in Welsh R (ed): Cataract Surgery. Miami Educational Press, 1969, p 196 5. Lemp MA, Pfister RR, Dohlmann CH: The effect of intraocular surgery on clear corneal grafts. Am ] Ophthalmol 77:824, 1974 6. Kaufman HE: Combined keratoplasty and cataract extraction. Am] Ophthalmol 77:824, 1974
7. Troutman E: Aphakic and combined grafts, in Emery J (ed): Current Concepts of Cataract Surgery: Selected Proceedings of the Fourth Biennial Cataract Surgical Congress. St. Louis, CVMosby Co, 1976, p 160
8. Hyde LL: Extracapsular cataract extraction combined with corneal grafting, in Emery J (ed): Current Concepts of Cataract Surgery: Selected Proceedings of the Fourth Biennial Cataract Surgical Congress. SI. Louis, CV Mosby Co, 1976, P 162 , 9. Polack FM: Corneal Transplantation. Grune and Stratton, 1978, p 158 10. Taylor DM: Keratoplasty and intraocular lenses. OphthalmIc Surg 7(1):31, 1976 II. Taylor DM: Keratoplasiy and intraocular lenses; follow-up study. Ophthalmic SUTg 8(2):49, 1977 12. Lee JR, Dohlman C: Intraocular lens implantation in combination with keratoplasty. Annals Ophthalmol9:513, 1977 13. Alpar 11: Keratoplasty with primary and secondary lens implantations. Ophthalmic Surg 9:59, 1978 14. Buxton IN, Jaffe MS: Combined keratoplasty, cataract extraction with intraocular lens implantation. Am IntraOcular Imp Soc] 4: 110, 1978 15. Gills JP: Constant mild compression of the eye to produce hypotension. Am Intra-Ocular Imp Soc] 5:52, 1979 16. McCarey BE, Kaufman HE: Improved corneal storage. Invest Ophthalmol 13: 165, 1974 17. Hoffer KJ: Corneal decompensation after corneal endothethelium cell count. Am ] Ophthalmol 84:252, 1978 18. Worst JGF: Extracapsular surgery in lens implantation. Am Intra-Ocular Imp Soc] 4(1) :7, 1978
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AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JULY 1979