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Triple Procedure—Method of Choice for Cataractous Eyes with Corneal Pathology
Triple Procedure - Method of Choice for Cataractous Eyes with Corneal Pathology LJERKA HENC-PETRINOVIC, NIKICA GABRIC, MLADEN BUSIC, IVA DEKARIS and JELENA PETRINOVIC-DORESIC Department of Ophthalmology, General Hospital, 'Sveti Duh' Zagreb, Croatia
L. Henc-Petrinovic, N. Gabric, M. Busic, I. Dekaris and J. Petrinovic-Doresic. Triple Procedure - Method of Choice for Cataractous Eyes with Corneal Pathology. Eur. J. Implant Ref. Surg., 1995; 7: 160-163. OBJECTIVES: Combined method of surgery - 'triple procedure' (extracapsular cataract extraction, posterior chamber lens implantation and partial perforative keratoplasty) was used to restore visual functions of cataractous eyes with coincident corneal pathology. Additional surgeries (synechiolysis, trabeculectomy, pupiloplasty) were done in complicated cases. PATIENTS: Postoperative results in 32 cataractous eyes of 31 patients (1 binocular case) having different kinds of corneal pathology were prospectively analysed. MAIN OUTCOME MEASURES: Complication rate, best corrected postoperative visual acuity after 3/6 months follow-up period. RESULTS: Posterior capsular fibrosis (14%) cystoid macular oedema (7%), graft rejection (6%) and other complications (9%) were late complications. Postoperative visual acuity ~ 0.4 was achieved in 51 % after 3, and in 81 % of patients after 6 months of postoperative follow-up. Strong corneal vascularization in 2 eyes compromised the graft, indicating rekeratoplasty. CONCLUSION: We find 'triple procedure' to be the method of choice for treatment of cataractous eye with associated corneal pathology. Additional surgeries (synechiolysis, trabeculectomy, pupiloplasty) help to solve complicated cases. Keywords: Keratoplasty; Cataract surgery; Intraocular lens implantation; Combined surgery.
INTRODUCTION
The most frequent ocular disorder occuring in eyes with corneal pathology is lens opacification. The combination of partial perforative keratoplasty (PPK) with extracapsular cataract extraction (ECCE) and posterior artificial lens implantation (PC-IOL) is the common solution for these coexisting problems. The alternative solution is the staged approach being in used in the 1960s. Frequent graft failure in the aphakic eye, as well as in eyes having cataract surgery after keratoplasty, was the immediate inducement for introducing combined surgery in such cases [1]. The evolution of intraocular lens implantation in the 1970s gave rise to modifications of cataract surgery from intracapsular to extrac0955-3681/95/030160 + 04 $08.0010
apsular and from iris or angular supported implants to posterior chamber lens implants [2]. The leading indication for triple procedure in the phakic eye is Fuchs endothelial dystrophy due to high incidence of cataract formation following keratoplasty [3, 4]. Postkeratitic and post-traumatic corneal leucoma, keratoconus, as well as fresh corneolenticular trauma, are other corneal pathologies indicating triple procedure. However, aphakic and pseudophakic keratopathy is recently reported as one of the most frequent overall indications [5]. Postoperative success depends not only on the applied surgical technique, but also on preoperative conditions of the eye, demanding, sometimes, additional elements of combined surgery such as synechiolysis, pupiloplasty, iridectomy or trabeculectomy. Degree and extension of corneal
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vascularization is substantially influencing the graft survival. The choice of the type of implant (anterior chamber or pupilar plane vs. posterior chamber implants) might also be decisive in postoperative outcome. The objective of this work was a 6-month follow-up study of a group of patients with heterogenous ocular pathology treated by combined procedure consisting of ECCE, PC-IOL, PPK and sometimes additional elements of surgery, depending on the case. The aim was to assess the complication rate, as well as the possibility of visual rehabilitation of the eyes with co-existing disorders of the anterior segment by means of combined surgery.
PATIENTS AND METHODS
Corneal pathology was accompanied by an opaque lens in 32 eyes of 31 patients (in one case the changes were binocular) of 10 men and 21 women. The average age of the patients was 59 years (ranging from 26 to 82 years). The corneal pathology Table 1 Corneal pathology in 32 eyes with coincident cataract, indicating triple procedure. Corneal pathology No. of eyes Post-traumatic scars 15 12 Postherpetic scars Corneal dystrophy 5 Thtal 32
in our group of patients is summarized in Table l. Post-traumatic leucoma with post-traumatic cataract was the most frequent indication, followed by postkeratitic scars with complicated, as well as agerelated lens opacifications. Corneal dystrophies (Fuchs endothelial dystrophy in 2 eyes, granular dystrophy of Groenouw in 2 eyes and central cloudy stromal dystrophy of Francois in 1 case). Corneal vascularization was present in 17 eyes; in 11 eyes over 1 quadrant, in 4 over 2, in 2 eyes of 1 binocular case over all 4 quadrants as a consequence of alkali corneo-conjunctival burns. Medically uncontrollable glaucoma in 1 patient, anterior synechiae in 5, posterior synechiae in 6 cases and iridal defect in 2 eyes were disorders associated with corneal pathology demanding additional elements of combined surgery in our patients. Preoperative visual acuity ranged from light projection in 21 eyes up to 0.1 in 11 eyes. Biomicroscopy, tonometry, echography and echobiometry were essential elements of preoperative examination. Calculation of predictive refractive power of the implant was performed using keratoEur J Implant Ref Surg, Vol 7, June 1995
metry readings of the pair eye, when possible, or by using standard keratometric value (43 x 43 D). Partial perforative keratoplasty was done in combination with ECCE and PC-IOL in all eyes. The size of the graft was 7.0 mm in 28 eyes with diameter disparity of 0.5 mm. In 4 eyes, 7.5 mm graft size was applied. Continuous 10-0 nylon monofilament suture was used for closing of the corneal wound. Additional surgeries were performed Table 2 Associated disorders in 32 eyes where triple procedure was completed by additional surgeries. Associated disorder No. Additional surgery Glaucoma 1 Trabecu1ectomy Posterior synechiae 6 Posterior synechiolysis Anterior synechiae 5 Anterior synechiolysis Iris defect 2 PupiIoplasty
as cited in Table 2: trabeculectomy was performed in 1 eye, anterior synechiolysis in 5 eyes, posterior synechiolysis in 6 and pupiloplasty in 2 eyes. Intraoperative anterior chamber haemorrhage occured in 5 eyes following synechiolysis, due to neovascular formations present in post-traumatic cases.
RESULTS
During the 6 month follow-up period, different postoperative complications occured. Controls comprised the whole group with daily visits for the first 2 weeks, once or twice a week for the first month and monthly controls until the end of the first year. Wound closure, anterior chamber contents, intraocular pressure, position of the implant and possible signs of inflammation or rejection were observed and noted. Early postoperative complications regarding corneal graft were epithelial exfoliation with or without endothelial oedema. Transitory elevated intraocular pressure was regulated by Diamox perorally, while sterile hypopion in 1 eye was treated topically and by Dexamethason parabulbar injections once or twice a day. Cortical remnants were the most common cause of persistent irritation demanding mydriatics (Table 3). Table 3 Early postoperative complications in a group of 32 eyes after triple procedure. No. Early postoperative complications 6 Epithelial exfoliation 5 Endothelial oedema 3 Elevated intraocular pressure 1 Sterile hypopion 4 Cortical remnants
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Late postoperative complications related to corneal transplantation were astygmatism (more than 6 D) in 4 eyes and graft rejection in 2 eyes with opaque oedematous graft 2 and 4 months after the Table 4 Late postoperative complications in a period of 6 months after triple procedure being done in 32 eyes. Late postoperative complications No. % Posterior capsule fibrosis 5 14 2 7 Cystoid macular oedema 4 9 Astigmatism (>6 D) Graft rejection 2 7
surgery (Table 4). In both of the cases preoperative vascularization of the recipient cornea was present in all 4 quadrants. Posterior capsular fibrosis, reducing visual acuity was treated by YAG laser capsulotomy in 5 eyes. Cystoid macular oedema developed in 2 eyes with worsening of the initialy-improved visual acuity. Amelioration of preoperative poor visual acuity was significant after 3, as well as after 6 months Table 5 Visnal acuity amelioration in 32 eyes 3/6 months postoperatively. Postoperative Visual acuity Preoperative 3 months 6 months 0 0 21 L+P+ 0.01-0.05 1 1 9 0.06-'0.10 2 8 1 0.20-0.40 16 26 0 ;,,0.50 7 4 0 Total. 32 32 32
following the surgery. This is presented in Table 5. One half of the group gained visus equal or more than 0.5 after 3 months postoperatively, however, 6 months after the surgery 81% of the eyes reached this visual acuity.
DISCUSSION
Diversity of indications for triple procedure in our group of patients, as well as different combinations of the elements of combined surgery used, make the subgroups too small to assess the differences of postoperative success and complication rate between them. However, it was still recognizable that pre-existent complications such as sequelae of earlier trauma or inflammation strongly influenced the outcome of the surgeries. Corneal and iridal neovascularization was the source of intraoperative, as well as the postoperative complications. Assessing the degree of lens opacification was difficult in the cases of total corneal leucoma, but the older age of our patients was a premise to presume
that age-related cataract might already be present. In several younger patients the decision was made intraoperatively, after removal of the opaque cornea. The dilema between the staged approach for dealing with combined corneal and cataract disease and combined surgery (PPK and ECCE with PC-IOL insertion) has been present as long as the triple procedure had been introduced. Because the postoperative course after cataract surgery leads to additional endothelial cell loss of the earlier-placed corneal graft, this sequence of single procedures increases the risk of graft survival. Conversely, patients with early cataracts will not be satisfied after only PPK done due to poor visual rehabilitation resulting from the precipitating effect of corneal surgery on cataract formation [3, 4]. This is of special importance for children with corneolenticular trauma, where expeditious visual rehabilitation is needed [6]. Compared with single surgery modalities, the combined triple procedure allows faster visual rehabilitation. There are certain drawbacks of the combined procedure, concerning accuracy of preoperative selection of lens implant power on one hand, and higher potential risk of complications due to prolonged operating time on the other. As the preoperative keratometry values of the donor cornea remain unknown on one side, and the keratometry values of the host cornea, if measurable, are altered by keratoplasty, on the other side, the accuracy of the IOL calculation diminishes with triple procedure. Higher accuracy of preoperative calculations is the advantage of the staged method consisting of initial penetrating keratoplasty followed later by phacoemulsification and PC-IOL implantation, where the calculations using postkeratometry stable values are more reliable. Preoperative echo biometry in our group of patients was performed on both eyes, wherever it was possible, so we determined the refractive status of the fellow eye to presume keratometry values of the eye to be operated. If the measurements were not possible we used standard keratometric values (43 X 43 D). Postoperative refractive error within ± 2 D was obtained in half of the preoperatively phakic subgroup of patients, more often on the positive side, presumably due to applanation of the central part of the graft. Higher potential risk of complications due to prolonged operating time in combined surgery in comparison with single procedures should be kept in mind in patients having risk for choroidal haemorrhage (repeated intrabulbar operations, advanced age, glaucoma). Although this devasting complication is more likely to occur in longer lasting 'open Eur J Implant Ref Surg, Vol 7, June 1995
Triple Procedure - Method of Choice
sky' surgery such as triple procedure we had no such case in our group. Graft rejection rate in our group followed for 6 months was 12% (6 eyes with transitory graft opacification controlled by local administration of corticosteroids) that is in accordance with data from the literature [7-9].
CONCLUSION
Inspite of possible intra- and postoperative complications we believe that combined PPK and ECCE followed by PC-IOL, as well as, by other additional procedures indicated for certain cases (synechiolysis, pupiloplasty, iridectomy or trabeculectomy etc.), might be the approach of choice for the patients with complicated corneal and lens disorders requiring surgery for visual rehabilitation.
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REFERENCES 1 DM Taylor. Keratoplasty and intraocular lenses. Ophthal. Surg., 1976; 7(1): 31-42. 2 C Skorpik, R Menapace, HD Gnad, M Grasl. The triple procedure-results in cataract patients with corneal opacity. Ophthalmologica, 1988; 196(1): 1- 6. 3 TP Martin, JW Reed, C Legault et al. Cataract formation and cataract extraction after penetrating keratoplasty. Ophthalmology, 1994; 101(1): 113-119. 4 GJ Pamel, DM Taylor. Combined procedures. In: FS Brightbill (ed.) Corneal Surgery: Mosby, St. Louis, USA, 177-183, 1993. 5 M Kuchle, KW Ruprecht, GK Lang, A Handel, GOH Naumann. Perforierende Keratoplastik bei Pseudophakie. Klin. Mbl. Augenheilk., 1988; 192: 637-643. 6 RB Vajpayee, SK Angra, SG Honavar. Combined keratoplasty, cataract extraction, and intraocular lens implantation after corneolenticular laceration in children. Am. J. Ophthalmol., 1994; 117: 507-511. 7 RF Meyer, DC Musch. Assessment of success and complications of triple procedure surgery. Trans. Am. Acad. Ophthal. Soc., 1987; 85: 350--367. 8 MS Insler, MS Kook, HE Kaufman. Penetration keratoplasty for pseudophakic bullous keratopathy associated with semiflexible closed-loop anterior chamber intraocular lenses. Am. J. Ophthalmol. , 1989; 107(3): 252-256. 9 DS Durrie, TB Cavanaugh. Combined procedures. In: FS Brightbill (ed.) Corneal Surgery: Mosby, St. Louis, USA, 184-192, 1993.
L. Henc-Petrinovic, N. Gabric, M. Busic, I. Dekaris and J. Petrinovic-Doresic. Triple Procedure - Method of Choice for Cataractous Eyes with Corneal Pathology. Eur. J. Implant Ref. Surg., 1995; 7: 160-163. OBJECTIVES: Combined method of surgery - 'triple procedure' (extracapsular cataract extraction, posterior chamber lens implantation and partial perforative keratoplasty) was used to restore visual functions of cataractous eyes with coincident corneal pathology. Additional surgeries (synechiolysis, trabeculectomy, pupiloplasty) were done in complicated cases. PATIENTS: Postoperative results in 32 cataractous eyes of 31 patients (1 binocular case) having different kinds of corneal pathology were prospectively analysed. MAIN OUTCOME MEASURES: Complication rate, best corrected postoperative visual acuity after 3/6 months follow-up period. RESULTS: Posterior capsular fibrosis (14%) cystoid macular oedema (7%), graft rejection (6%) and other complications (9%) were late complications. Postoperative visual acuity ~ 0.4 was achieved in 51 % after 3, and in 81 % of patients after 6 months of postoperative follow-up. Strong corneal vascularization in 2 eyes compromised the graft, indicating rekeratoplasty. CONCLUSION: We find 'triple procedure' to be the method of choice for treatment of cataractous eye with associated corneal pathology. Additional surgeries (synechiolysis, trabeculectomy, pupiloplasty) help to solve complicated cases. Keywords: Keratoplasty; Cataract surgery; Intraocular lens implantation; Combined surgery.
INTRODUCTION
The most frequent ocular disorder occuring in eyes with corneal pathology is lens opacification. The combination of partial perforative keratoplasty (PPK) with extracapsular cataract extraction (ECCE) and posterior artificial lens implantation (PC-IOL) is the common solution for these coexisting problems. The alternative solution is the staged approach being in used in the 1960s. Frequent graft failure in the aphakic eye, as well as in eyes having cataract surgery after keratoplasty, was the immediate inducement for introducing combined surgery in such cases [1]. The evolution of intraocular lens implantation in the 1970s gave rise to modifications of cataract surgery from intracapsular to extrac0955-3681/95/030160 + 04 $08.0010
apsular and from iris or angular supported implants to posterior chamber lens implants [2]. The leading indication for triple procedure in the phakic eye is Fuchs endothelial dystrophy due to high incidence of cataract formation following keratoplasty [3, 4]. Postkeratitic and post-traumatic corneal leucoma, keratoconus, as well as fresh corneolenticular trauma, are other corneal pathologies indicating triple procedure. However, aphakic and pseudophakic keratopathy is recently reported as one of the most frequent overall indications [5]. Postoperative success depends not only on the applied surgical technique, but also on preoperative conditions of the eye, demanding, sometimes, additional elements of combined surgery such as synechiolysis, pupiloplasty, iridectomy or trabeculectomy. Degree and extension of corneal
160
© 1995 W.B. Saunders Company Limited
161
Triple Procedure - Method of Choice
vascularization is substantially influencing the graft survival. The choice of the type of implant (anterior chamber or pupilar plane vs. posterior chamber implants) might also be decisive in postoperative outcome. The objective of this work was a 6-month follow-up study of a group of patients with heterogenous ocular pathology treated by combined procedure consisting of ECCE, PC-IOL, PPK and sometimes additional elements of surgery, depending on the case. The aim was to assess the complication rate, as well as the possibility of visual rehabilitation of the eyes with co-existing disorders of the anterior segment by means of combined surgery.
PATIENTS AND METHODS
Corneal pathology was accompanied by an opaque lens in 32 eyes of 31 patients (in one case the changes were binocular) of 10 men and 21 women. The average age of the patients was 59 years (ranging from 26 to 82 years). The corneal pathology Table 1 Corneal pathology in 32 eyes with coincident cataract, indicating triple procedure. Corneal pathology No. of eyes Post-traumatic scars 15 12 Postherpetic scars Corneal dystrophy 5 Thtal 32
in our group of patients is summarized in Table l. Post-traumatic leucoma with post-traumatic cataract was the most frequent indication, followed by postkeratitic scars with complicated, as well as agerelated lens opacifications. Corneal dystrophies (Fuchs endothelial dystrophy in 2 eyes, granular dystrophy of Groenouw in 2 eyes and central cloudy stromal dystrophy of Francois in 1 case). Corneal vascularization was present in 17 eyes; in 11 eyes over 1 quadrant, in 4 over 2, in 2 eyes of 1 binocular case over all 4 quadrants as a consequence of alkali corneo-conjunctival burns. Medically uncontrollable glaucoma in 1 patient, anterior synechiae in 5, posterior synechiae in 6 cases and iridal defect in 2 eyes were disorders associated with corneal pathology demanding additional elements of combined surgery in our patients. Preoperative visual acuity ranged from light projection in 21 eyes up to 0.1 in 11 eyes. Biomicroscopy, tonometry, echography and echobiometry were essential elements of preoperative examination. Calculation of predictive refractive power of the implant was performed using keratoEur J Implant Ref Surg, Vol 7, June 1995
metry readings of the pair eye, when possible, or by using standard keratometric value (43 x 43 D). Partial perforative keratoplasty was done in combination with ECCE and PC-IOL in all eyes. The size of the graft was 7.0 mm in 28 eyes with diameter disparity of 0.5 mm. In 4 eyes, 7.5 mm graft size was applied. Continuous 10-0 nylon monofilament suture was used for closing of the corneal wound. Additional surgeries were performed Table 2 Associated disorders in 32 eyes where triple procedure was completed by additional surgeries. Associated disorder No. Additional surgery Glaucoma 1 Trabecu1ectomy Posterior synechiae 6 Posterior synechiolysis Anterior synechiae 5 Anterior synechiolysis Iris defect 2 PupiIoplasty
as cited in Table 2: trabeculectomy was performed in 1 eye, anterior synechiolysis in 5 eyes, posterior synechiolysis in 6 and pupiloplasty in 2 eyes. Intraoperative anterior chamber haemorrhage occured in 5 eyes following synechiolysis, due to neovascular formations present in post-traumatic cases.
RESULTS
During the 6 month follow-up period, different postoperative complications occured. Controls comprised the whole group with daily visits for the first 2 weeks, once or twice a week for the first month and monthly controls until the end of the first year. Wound closure, anterior chamber contents, intraocular pressure, position of the implant and possible signs of inflammation or rejection were observed and noted. Early postoperative complications regarding corneal graft were epithelial exfoliation with or without endothelial oedema. Transitory elevated intraocular pressure was regulated by Diamox perorally, while sterile hypopion in 1 eye was treated topically and by Dexamethason parabulbar injections once or twice a day. Cortical remnants were the most common cause of persistent irritation demanding mydriatics (Table 3). Table 3 Early postoperative complications in a group of 32 eyes after triple procedure. No. Early postoperative complications 6 Epithelial exfoliation 5 Endothelial oedema 3 Elevated intraocular pressure 1 Sterile hypopion 4 Cortical remnants
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Late postoperative complications related to corneal transplantation were astygmatism (more than 6 D) in 4 eyes and graft rejection in 2 eyes with opaque oedematous graft 2 and 4 months after the Table 4 Late postoperative complications in a period of 6 months after triple procedure being done in 32 eyes. Late postoperative complications No. % Posterior capsule fibrosis 5 14 2 7 Cystoid macular oedema 4 9 Astigmatism (>6 D) Graft rejection 2 7
surgery (Table 4). In both of the cases preoperative vascularization of the recipient cornea was present in all 4 quadrants. Posterior capsular fibrosis, reducing visual acuity was treated by YAG laser capsulotomy in 5 eyes. Cystoid macular oedema developed in 2 eyes with worsening of the initialy-improved visual acuity. Amelioration of preoperative poor visual acuity was significant after 3, as well as after 6 months Table 5 Visnal acuity amelioration in 32 eyes 3/6 months postoperatively. Postoperative Visual acuity Preoperative 3 months 6 months 0 0 21 L+P+ 0.01-0.05 1 1 9 0.06-'0.10 2 8 1 0.20-0.40 16 26 0 ;,,0.50 7 4 0 Total. 32 32 32
following the surgery. This is presented in Table 5. One half of the group gained visus equal or more than 0.5 after 3 months postoperatively, however, 6 months after the surgery 81% of the eyes reached this visual acuity.
DISCUSSION
Diversity of indications for triple procedure in our group of patients, as well as different combinations of the elements of combined surgery used, make the subgroups too small to assess the differences of postoperative success and complication rate between them. However, it was still recognizable that pre-existent complications such as sequelae of earlier trauma or inflammation strongly influenced the outcome of the surgeries. Corneal and iridal neovascularization was the source of intraoperative, as well as the postoperative complications. Assessing the degree of lens opacification was difficult in the cases of total corneal leucoma, but the older age of our patients was a premise to presume
that age-related cataract might already be present. In several younger patients the decision was made intraoperatively, after removal of the opaque cornea. The dilema between the staged approach for dealing with combined corneal and cataract disease and combined surgery (PPK and ECCE with PC-IOL insertion) has been present as long as the triple procedure had been introduced. Because the postoperative course after cataract surgery leads to additional endothelial cell loss of the earlier-placed corneal graft, this sequence of single procedures increases the risk of graft survival. Conversely, patients with early cataracts will not be satisfied after only PPK done due to poor visual rehabilitation resulting from the precipitating effect of corneal surgery on cataract formation [3, 4]. This is of special importance for children with corneolenticular trauma, where expeditious visual rehabilitation is needed [6]. Compared with single surgery modalities, the combined triple procedure allows faster visual rehabilitation. There are certain drawbacks of the combined procedure, concerning accuracy of preoperative selection of lens implant power on one hand, and higher potential risk of complications due to prolonged operating time on the other. As the preoperative keratometry values of the donor cornea remain unknown on one side, and the keratometry values of the host cornea, if measurable, are altered by keratoplasty, on the other side, the accuracy of the IOL calculation diminishes with triple procedure. Higher accuracy of preoperative calculations is the advantage of the staged method consisting of initial penetrating keratoplasty followed later by phacoemulsification and PC-IOL implantation, where the calculations using postkeratometry stable values are more reliable. Preoperative echo biometry in our group of patients was performed on both eyes, wherever it was possible, so we determined the refractive status of the fellow eye to presume keratometry values of the eye to be operated. If the measurements were not possible we used standard keratometric values (43 X 43 D). Postoperative refractive error within ± 2 D was obtained in half of the preoperatively phakic subgroup of patients, more often on the positive side, presumably due to applanation of the central part of the graft. Higher potential risk of complications due to prolonged operating time in combined surgery in comparison with single procedures should be kept in mind in patients having risk for choroidal haemorrhage (repeated intrabulbar operations, advanced age, glaucoma). Although this devasting complication is more likely to occur in longer lasting 'open Eur J Implant Ref Surg, Vol 7, June 1995
Triple Procedure - Method of Choice
sky' surgery such as triple procedure we had no such case in our group. Graft rejection rate in our group followed for 6 months was 12% (6 eyes with transitory graft opacification controlled by local administration of corticosteroids) that is in accordance with data from the literature [7-9].
CONCLUSION
Inspite of possible intra- and postoperative complications we believe that combined PPK and ECCE followed by PC-IOL, as well as, by other additional procedures indicated for certain cases (synechiolysis, pupiloplasty, iridectomy or trabeculectomy etc.), might be the approach of choice for the patients with complicated corneal and lens disorders requiring surgery for visual rehabilitation.
Eur J Implant Ref Surg. Vol 7. June 1995
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REFERENCES 1 DM Taylor. Keratoplasty and intraocular lenses. Ophthal. Surg., 1976; 7(1): 31-42. 2 C Skorpik, R Menapace, HD Gnad, M Grasl. The triple procedure-results in cataract patients with corneal opacity. Ophthalmologica, 1988; 196(1): 1- 6. 3 TP Martin, JW Reed, C Legault et al. Cataract formation and cataract extraction after penetrating keratoplasty. Ophthalmology, 1994; 101(1): 113-119. 4 GJ Pamel, DM Taylor. Combined procedures. In: FS Brightbill (ed.) Corneal Surgery: Mosby, St. Louis, USA, 177-183, 1993. 5 M Kuchle, KW Ruprecht, GK Lang, A Handel, GOH Naumann. Perforierende Keratoplastik bei Pseudophakie. Klin. Mbl. Augenheilk., 1988; 192: 637-643. 6 RB Vajpayee, SK Angra, SG Honavar. Combined keratoplasty, cataract extraction, and intraocular lens implantation after corneolenticular laceration in children. Am. J. Ophthalmol., 1994; 117: 507-511. 7 RF Meyer, DC Musch. Assessment of success and complications of triple procedure surgery. Trans. Am. Acad. Ophthal. Soc., 1987; 85: 350--367. 8 MS Insler, MS Kook, HE Kaufman. Penetration keratoplasty for pseudophakic bullous keratopathy associated with semiflexible closed-loop anterior chamber intraocular lenses. Am. J. Ophthalmol. , 1989; 107(3): 252-256. 9 DS Durrie, TB Cavanaugh. Combined procedures. In: FS Brightbill (ed.) Corneal Surgery: Mosby, St. Louis, USA, 184-192, 1993.