From the Department of Ophthalmology, Ilsan Paik Hospital, Inje University, Kyunggyi, Korea.
The authors have no proprietary interest in the materials presented herein.
Study concept and design (D.L., J.H.K.); data collection (S.K.C.); interpretation and analysis of data (S.H.O., J.K.K.); drafting of the manuscript (S.H.O., S.K.C.); critical revision of the manuscript (D.L., J.H.K., J.K.K.); administrative, technical, or material support (D.L., J.H.K., J.K.K.)
Correspondence: Doh Lee, MD, PhD, Dept of Ophthalmology, Ilsan Paik Hospital, Inje University Medical College, 2240 Dae Wha-dong, Ilsan-ku, Koyang, Kyunggyi-do, 411-706, Korea. Tel: 82 31 910 7240; Fax: 82 31 911 7241; E-mail: firstname.lastname@example.org
In patients with cataracts combined with corneal opacity, cataract surgery can be difficult. One option for these patients is cataract surgery with penetrating keratoplasty. This procedure, however, is associated with several intra- and postoperative complications.1–5 Recently, microkeratome-assisted cataract surgery has been reported to be useful in patients with a cloudy cornea.6–8 Flap lift during surgery gives the surgeon a better view during the procedure. However, the fixed flap thickness resulting from this procedure reduces the possible surgical indications.
The development of the femtosecond laser (IntraLase; Advanced Medical Optics, Irvine, Calif) enables corneal surgery involving lamellar resection, in which the surgeon can select the diameter and thickness of the tissue to be resected. If the opaque portion of the cornea is eliminated with the femtosecond laser, cataract surgery is easier and safer. We report a new surgical strategy to treat a cataract patient with corneal opacity.
A 63-year-old woman was referred to our department with complaints of a visual disturbance in her left eye. Visual acuity was counting fingers with the left eye but only hand movement with the right eye. The right eye showed thick corneal opacity and brunescent cataractous lens opacity. She had been unable to see with her right eye since childhood.
Slit-lamp examination showed a central, thick corneal stromal opacity with inferior neovascularization in the left eye (Fig A). The corneal opacity extended over more than half the thickness of the cornea. Lens opacity examination revealed grade III nuclear sclerosis. Combined lamellar keratoplasty using the IntraLase 60-KHz femtosecond laser and cataract surgery on the left eye was planned. The surgical procedure was approved by the Institutional Review Board of Inje University and informed consent was obtained from the patient before surgery.
Figure. Slit-Lamp Photographs of a 63-Year-Old Woman with Cataract and Corneal Opacity Who Underwent Femtosecond Laser–Assisted Cataract Surgery with Lamellar Keratoplasty. A) A Central, Thick Corneal Opacity with Neo-Vascularization. B) Excimer Laser Phototherapeutic Keratectomy Was Performed After Removal of the Corneal Graft to Smooth the Surface of the Residual Stromal Bed. C) Phacoemulsification of Cataract Was Performed with the Removal of the Corneal Graft. The Entire Procedure Was Performed Without Difficulty and Was Similar to Routine Surgeries. D) Photograph Taken 1 Week Postoperatively Shows the Donor Graft Was Well-Positioned on the Recipient Cornea Without Sutures. Although Remnant Deep Stromal Opacity Was Noted, the Improvement in Visual Acuity to 20/200 Was Sufficient to Allow the Patient to Perform Daily Routines Without Help.
Preoperatively, the thicknesses of lamellar dissections of the donor and recipient corneas were determined. Anterior corneal optical computed tomography (OCT) (Visante OCT; Carl Zeiss Meditec, Jena, Germany) showed that the thickness of the recipient cornea was 650 μm. Swelling of the donor cornea was considered when calculating the approximate ratio of donor corneal thickness (swollen) and average corneal thickness (not swollen). The planned thickness of the donor cornea could be calculated based on the desired thickness obtained using this ratio. The donor graft size was chosen to be 0.1 mm larger than the cornea of the recipient. We used a donor eye with a fresh whole eyeball. A flap was created with the IntraLase 60-KHz femtosecond laser under topical anesthesia. Planned flap thickness and diameter were 400 mm and 7.6 mm, respectively, without pocket formation. The pulse energy used to create the flap was 1.0 μJ. The spacing between each laser spot and the raster line was 7×7 mm. The side-cut energy was 1.0 μJ, and the side-cut angle was 70°.
Lamellar dissection of the recipient cornea was performed under topical anesthesia using the Intra-Lase 60-KHz femtosecond laser. Lamellar dissection thickness and diameter of the recipient cornea were 350 mm and 7.5 mm, respectively. The energy used to create the flap was 1.5 μJ. The spacing between each laser spot and the raster line was 7×7 mm. The side-cut energy was 1.5 μJ, and the side-cut angle was 70°. Under the microscope, the lamellar graft was removed using a flap elevator without difficulty. The surface of the residual stromal bed was irregular owing to adherence of fibrotic tissue of the scarred cornea. Phototherapeutic keratectomy using an excimer laser (Technolas 217 Z100; Bausch & Lomb, Rochester, NY) was performed to smooth the stromal surface (7-mm optical zone, 35-μm ablation depth) (Fig B).
After removal of the recipient corneal graft, cataract surgery was performed (Fig C). Although corneal opacity remained, the anterior chamber and lens were better visualized through the cornea during the entire procedure. After intraocular lens implantation, the donor graft was placed on the recipient cornea. No suture was used between the recipient and donor corneas, and a bandage contact lens was applied. After surgery, the patient was treated with topical levofloxacin, 1% prednisolone, and a tear substitute for 3 weeks.
On the first postoperative day, the donor graft was well-positioned on the recipient cornea and no inflammation was noted. The bandage contact lens was removed after 7 days (Fig D). Although corneal opacity was still present in the recipient cornea, the visual acuity improved from finger counting to 20/200. After 12-month follow-up, the patient’s vision and cornea were stable with manifest refraction +3.00 diopters of sphere, and the patient could perform daily routines without help.
Many surgical trials have been performed in patients with cataracts and corneal opacity.1,7 However, our patient had only one functional eye, so possible intra- and postoperative complications of penetrating keratoplasty were unacceptable. Microkeratome-assisted cataract surgery is a challenging procedure and is limited by the depth and severity of the opacity. In addition, some complications associated with a microkeratome have been reported in corneas that are particularly steep or particularly flat, especially in opaque corneas with vague keratometric values.8,9 As an alternative, we designed femtosecond laser–assisted cataract surgery. Patient suitability for this surgical procedure is determined based on the intensity and depth of the corneal opacity. If the opacity does not obscure the central cornea and is limited to the anterior half of the cornea, a corneal flap can be made using the femtosecond laser. If the opacity obscures the central cornea and is located in the posterior half of the cornea, combined lamellar keratoplasty should be performed. The decision regarding whether to perform lamellar keratoplasty, penetrating keratoplasty, or deep lamellar keratoplasty to restore vision depends on the level of the opacity in the cornea.
Preoperative anterior OCT is useful in determining the thickness of the lamellar dissection of the recipient cornea. However, there is no gold standard as to how the thickness of the donor cornea, which is usually edematous, should be determined. In this case, we first determined the thickness of lamellar dissection of the recipient cornea based on preoperative anterior OCT.10 The transplanted thickness of the donor cornea was determined by calculating the ratio of the donor corneal thickness (swollen) and the average corneal thickness. The planned thickness of the donor cornea could be calculated from this ratio and from the thickness of the lamellar dissection of the recipient cornea.
In this patient, no sutures were needed for lamellar graft, and only a bandage contact lens was used because the femtosecond laser enabled the transplanted margin between the donor and recipient to fit sufficiently well, which not only prevented this combined procedure from being complicated and time-consuming, but also from producing more astigmatism than cataract surgery alone.
Femtosecond laser–assisted cataract surgery is a promising strategy in patients with cataracts combined with anterior stromal opacity of the cornea due to improved visualization during surgery. Furthermore, this technique may help avoid or defer penetrating keratoplasty.
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