Cataract surgery after corneal transplant must minimize endothelial cell damage because postoperative transplant cell counts are lower than those of normal corneas. As the femtosecond laser was successfully introduced in cataract surgery,1,2 we applied this technology in an eye that had a previous penetrating corneal transplant.
A 33-year-old man had a 7.0-mm diameter penetrating keratoplasty in his right eye 6 years prior to presentation. He later developed posterior polar cataract. The cornea was clear and corrected distance visual acuity (CDVA) was 20/40. Femtosecond laser–assisted cataract surgery (Alcon LenSx, Aliso Viejo, California) was performed as described previously.1,2 The corneal scar was peripheral to the planned capsulotomy. Centration was assessed using the pupillary edge. A 4.8-mm capsulorrhexis was performed with the femtosecond laser and the nucleus was liquefied.
Corneal wounds were created with a 2.8-mm and 15° blade so as not to interfere with the transplant scar. The anterior chamber was filled with viscoelastic material, and the edge of the capsulorrhexis was identified with a cystotome and removed with a capsulorrhexis forceps. After hydrodissection, the lens nucleus and cortex were aspirated with the irrigation-aspiration handpiece. A +12.00-diopter (D) hydrophobic acrylic posterior chamber intraocular lens (Acrysof; Alcon Laboratories Inc, Ft Worth, Texas) was implanted in the capsular bag.
On postoperative day 1, CDVA was 20/200 because of slight corneal edema, which improved to 20/25 over the next 3 months. Subjective refraction was stable at +1.25 D sphere and −6.00 D cylinder at 1-year follow-up, with CDVA of 20/20. Corneal thickness measured with a Scheimpflug camera (Pentacam HR; Oculus Optikgeräte GmbH, Wetzlar, Germany) was 609 μm preoperatively and 598 μm 1 month postoperatively.
We report the first patient having successful laser refractive cataract surgery after penetrating keratoplasty. The curved interface aligned perfectly along the transplanted and donor cornea. Optical coherence tomography identified the scar line of the transplant and the scar did not interfere with the laser capsulotomy. The corneal incisions were created manually because of the peripheral localization of the transplant scar.
As reported previously,1 the use of a femtosecond laser may minimize the ultrasound energy required to remove the nucleus, thereby preserving endothelial cells in postoperative transplant corneas. Graft failure following phacoemulsification and intraocular lens implantation is reported to be between 3% and 8%.3,4 Endothelial cell loss related to ultrasound use is usually markedly higher in transplanted corneas than in normal, unoperated eyes.5 In our case, most likely due to the use of the femtosecond laser to liquefy the nucleus, no ultrasound was required to remove the lens and endothelial cell count did not change up to 1 year after surgery.
Zoltán Z. Nagy, MD, DSC
Ágnes I. Takács, MD
Tamás Filkorn, MD
Éva Juhász, MD
Gábor Sándor, MD
Andrea Szigeti, MD
Michael C. Knorz, MD
- Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12):1053–1060. doi:10.3928/1081597X-20091117-04 [CrossRef]
- Nagy ZZ, Kranitz K, Takacs AI, Mihaltz K, Kovacs I, Knorz MC. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg. 2011;27(8):564–569. doi:10.3928/1081597X-20110607-01 [CrossRef]
- Ohguro N, Matsuda M, Kinoshita S. Effects of posterior chamber lens implantation on the endothelium of transplanted corneas. Br J Ophthalmol. 1997;81(12):1056–1059. doi:10.1136/bjo.81.12.1056 [CrossRef]
- Nagra PK, Rapuano CJ, Laibson PL, Kunimoto DY, Kay M, Cohen EJ. Cataract extraction following penetrating keratoplasty. Cornea. 2004;23(4):377–379. doi:10.1097/00003226-200405000-00012 [CrossRef]
- Kim EC, Kim MS. A comparison of endothelial cell loss after phacoemulsification in penetrating keratoplasty patients and normal patients. Cornea. 2010;29(5):510–515. doi:10.1097/ICO.0b013e3181c11e0e [CrossRef]