From the Department of Ophthalmology (SKC, JHK, DL, JH), Ilsan Paik Hospital, Inje University, Kyunggyi-do; and Chung Ang University (NJM), Seoul, Korea.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Doh Lee, MD, PhD, Department of Ophthalmology, Ilsan Paik Hospital, Inje University Medical College, 2240 Dae Wha-dong, Ilsanseo-ku, Koyang, Kyunggyi-do, 411-706, Korea. E-mail: firstname.lastname@example.org
The closed system is preferred for cataract extraction during keratoplasty, primarily because the open-sky approach is associated with risks of several complications.1,2 However, the open-sky method is required for some patients presenting with thick corneal opacity. Therefore, several techniques have been introduced to reduce the risk of complications and to facilitate cataract extraction.3–6 These modifications have been designed to create safe and sufficiently large anterior capsulotomies and to prevent complications caused by positive vitreal pressure. We describe a case using a simple double-needle technique that allowed safe cataract extraction in the open-sky state.
A 38-year-old man with a history of corneal ulcers and penetrating keratoplasty in his right eye required penetrating keratoplasty for graft failure. The best-corrected visual acuity of his right eye was 20/2000. Slit-lamp biomicroscopic examination showed edematous corneal opacity and mature opacity of the crystalline lens. Patients were administered preoperative intravenous osmotic agents (200 g/day d-mannitol injection, 0.15 g/mL, 1 to 3 g/kg; CHOONGWAE Pharm, Hwaseong, Korea), followed by retrobulbar anesthesia and digital massage. Donor and recipient corneas were prepared using a femtosecond laser (60-kHz IntraLase; Abbott Medical Optics, Irvine, CA). After routine skin preparation, a Flieringa ring (K1-7150; Katena, Heidelberg, Germany) was sutured to the recipient eye. Before removal of the recipient corneal button, two 10-0 Prolene straight double-arm needles (W1713; Ethicon, Edinburgh, Scotland) were inserted transcorneally into the recipient bed from the 7- to 3-o’clock positions and from the 9- to 1-o’clock position, with a suitable distance between the two parallel needles (Fig. A). After removal of the recipient corneal button with corneal scissors, anterior capsulotomy was performed with a 26-gauge needle and continuous curvilinear capsulorrhexis forceps. After hydrodissection, the nucleus was removed by chopping and a simply prolapsed piece was removed with the assistance of a viscoelastic substance. After cortical clean up using an automated irrigation/aspiration unit, the capsular bag was inflated with a viscoelastic substance and an intraocular lens was implanted. Cardinal sutures were placed using 10-0 nylon (Fig. B), the needles were removed, and additional sutures were placed to secure the donor–recipient interface (Figs. C and D). There were no intraoperative complications.
Figure. The “double-Needle” Technique for Triple Surgery. (A) Two Needles Were Inserted into the Recipient Bed. (B) After Removal of the Recipient Cornea, the Lens Was Removed by Phacoemulsification and an Intraocular Lens Was Implanted in the Bag Without Difficulty. (C) Cardinal Suturing Was Performed. (D) The Needles Were Removed from the Recipient Bed and the Donor Cornea Was Secured with 10-0 Nylon.
The first difficult decision when performing combined penetrating keratoplasty and cataract extraction is how to obtain a clear surgical field for cataract surgery. Although closed cataract surgery is preferable if sufficient corneal transparency is present,7 an open-sky approach for cataract extraction may be preferred in some patients with thick corneal opacity. This approach renders many of the steps of cataract surgery more difficult, especially in terms of establishing and maintaining a continuous curvilinear capsulorrhexis.1,2 In addition, the positive vitreal pressure generated using the open-sky approach may lead to serious complications. This problem may be solved by using an artificially closed system, a temporary graft, or a temporary keratoprosthesis.8 However, this approach is time-consuming. A simpler method, such as modification of a soft contact lens, also cannot fully achieve closed-eye conditions and is applicable only to irrigation and aspiration.9 Posterior positive pressure may also be reduced using a spatula, vitreous tapping, core vitrectomy, or a combination of these.3,5 However, vitreous manipulation has many potential risks and makes it difficult to suture the cornea under hypotony.4,10 In addition, the use of a spatula is technically difficult and is therefore only used during continuous curvilinear capsulorrhexis.
We found that the use of two straight needles in open-sky surgery was simple and cost-effective, and afforded excellent results by stabilizing the lens–iris diaphragm throughout the surgery, especially during continuous curvilinear capsulorrhexis, as in the closed system. Two straight needles inserted transcorneally seemed to stabilize the eyeball contour by transcorneal fixation, so this technique can be used not only for triple surgery, but also for all types of penetrating keratoplasty in which vitreal pressure is a concern. This method has been used during penetrating keratoplasty in our institution and all procedures were uneventful. In pseudophakic keratoplasty, the method using two needles was better than a method using one straight needle, both for aphakic and pediatric cases.5 We have also found that the framing function of the two straight needles aided cardinal suturing because the recipient cornea is relatively well protected from distortion.
Although the two inserted needles did not impede the use of the irrigation and aspiration hand piece, a suitable distance between the two needles is required to ensure that the capsulotomy is of sufficient size. If a suitable distance between the two needles can be secured, the superior approach can be changed according to the needs of the patient or surgeon. Care should also be taken not to damage the iris or other structures of the anterior chamber angle during insertion of the needles through the recipient corneal bed.
Use of this technique had always been accompanied by preoperative intravenous injection of mannitol. Although this technique may be effective, we believe that other methods, such as mannitol and digital massage, are also effective in decreasing surgical risks due to vitreal pressure. In addition, this technique may be more helpful if there are concerns about complications due to preoperative or intraoperative mannitol use.
We have found that this technique was effective in preventing forward movement of the lens–iris diaphragm, anterior capsular tearing, rapid expulsion of the lens after capsulotomy, and difficulty in intraocular lens insertion during triple surgery in the open-sky state.
- Baca LS, Epstein RJ. Closed-chamber capsulorhexis for cataract extraction combined with penetrating keratoplasty. J Cataract Refract Surg. 1998;24:581–584.
- Chu TG, Green RL. Suprachoroidal hemorrhage. Surv Ophthalmol. 1999;43:471–486. doi:10.1016/S0039-6257(99)00037-5 [CrossRef]
- Gross RH, Shaw EL. Management of increased vitreous pressure during penetrating keratoplasty using pars plana anterior vitreous aspiration. Cornea. 2001;20:251–254. doi:10.1097/00003226-200104000-00003 [CrossRef]
- Vongthongsri A, Jakpaiwong W, Preechanon A, Lekhanont K, Chuck RS. Anterior vitreous tapping to manage positive vitreous pressure during triple procedures. Ophthalmology. 2005;112:875–878. doi:10.1016/j.ophtha.2004.12.027 [CrossRef]
- McCartney DL, Gottsch JD, Stark WJ. Managing posterior pressure during pseudophakic keratoplasty. Arch Ophthalmol. 1989;107:1384–1386.
- Ozkiris A, Arslan O, Cicik E, Köylüoglu N, Evereklioglu C. Open-sky capsulorrhexis in triple procedure: with or without trypan blue?Eur J Ophthalmol. 2003;13:764–769.
- 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. doi:10.1016/S0886-3350(00)00839-7 [CrossRef]
- 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. doi:10.1016/S0886-3350(01)00748-9 [CrossRef]
- Kawamoto K, Morishige N, Chikama T, Nishida T. Modification of a soft contact lens for use during irrigation and aspiration in the penetrating keratoplasty triple procedure. Arch Ophthalmol. 2006;124:550–551. doi:10.1001/archopht.124.4.550 [CrossRef]
- Konomi K, Shimazaki J, Shimmura S, Akabane N, Goto E, Tsubota K. Efficacy of core vitrectomy preceding triple corneal procedure. Br J Ophthalmol. 2004;88:1023–1025. doi:10.1136/bjo.2003.033902 [CrossRef]