femtosecond-assisted keratoplasty with fibrin glue–assisted sutureless posterior chamber lens...

Femtosecond-assisted keratoplasty with fibringlue–assisted sutureless posterior chamber lens

implantation: New triple procedureGaurav Prakash, MD, Soosan Jacob, MS, DNB, FRCS, Dhivya Ashok Kumar, MD,

Smita Narsimhan, FERC, Athiya Agarwal, MD, DO, Amar Agarwal, MS, FRCS, FRCOphth

We report a surgical technique for managing bullous keratopathy secondary to anterior chamberintraocular lens (AC IOL). The technique comprises femtosecond laser–assisted penetrating kera-toplasty and AC IOL exchange with fibrin glue–assisted sutureless posterior chamber intraocularlens (PC IOL) implantation (‘‘glued IOL’’). This new triple procedure combines the unique benefitsof the femtosecond laser and the glued IOL, leading to stable wound configuration, decreased open-sky time, and less pseudophacodonesis, and there is less risk for the suture-related complicationsof transscleral suture fixation.

J Cataract Refract Surg 2009; 35:973–979 Q 2009 ASCRS and ESCRS

TECHNIQUE

Pseudophakic bullous keratopathy (PBK) with ananterior chamber intraocular lens (AC IOL) is a leadingindication for full-thickness penetrating keratoplasty(PKP) and IOL exchange.1,2 It presents a unique surgi-cal challenge because of a previous complicatedsurgery, compromised aqueous drainage, unhealthywound configuration, and a deficient posteriorcapsule. Both the corneal transplantation and the IOLexchange should be optimized to achieve less ‘‘open-sky’’ time, easier intraoperative procedures, fasterwound healing, and maximum provision and postop-erative preservation of the donor endothelial cells.

A paradigm shift has occurred in keratoplasty withthe use of the femtosecond laser for sculpting the do-nor and host corneas. The top-hat configuration has

Submitted: October 1, 2008.Final revision submitted: November 30, 2008.Accepted: December 2, 2008.

From Dr Agarwal Eye Hospital and Eye Research Centre, Chennai,India.

Amar Agarwal is a consultant to Abott Medical Optics (formerlyAdvanced Medical Optics), Irvine, California, USA. No other authorhas a financial or proprietary interest in any material or methodmentioned.

Corresponding author: Amar Agarwal, MS, FRCS, FRCOphth, Pro-fessor and Head, Dr Agarwal Eye Hospital and Eye Research Centre,19, Cathedral Road, Chennai- 600 086, India. E-mail: [email protected].

Q 2009 ASCRS and ESCRS

Published by Elsevier Inc.

resulted in a more stable wound configuration, fasterhealing, and more endothelial cells (compared withthose in a standardmanual procedurewith a compara-ble epithelial side diameter).3–8

In contrast, current techniques for IOL exchangeduring keratoplasty, especially in caseswith a deficientposterior capsule, are less than satisfactory. Trans-sclerally sutured IOLs have been used in this situa-tion.9–10 Unfortunately, this technique is associatedwith a longer learning curve, prolonged intraoperativemanipulation, postoperative pseudophacodonesis,and chances of postoperative decentration due to su-ture degradation or knot slippage.10–17

We have successfully performed fibrin glue–assis-ted sutureless posterior chamber IOL (PC IOL) im-plantation in eyes with deficient posterior capsulesupport.18 It involves trans-scleral exteriorizationand intrascleral tuck of both the haptics under diamet-rically opposite scleral flaps, which are then apposedwith scleral glue. This sutureless technique can be per-formed with routinely available poly(methyl methac-rylate) (PMMA) PC IOLs and has a short learningcurve. In an ongoing trial, we have achieved satisfac-tory surgical time and safety, rehabilitation duration,and postoperative results in more than 100 eyes withpostsurgical aphakia or dislocated IOLs (unpublisheddata). There have been no cases of dislocation.

We describe a new triple procedure: femtosecond la-ser–assisted PKP, AC IOL explantation, and fibringlue–assisted sutureless IOL implantation in the pos-terior chamber for the management of PBK with an

0886-3350/09/$dsee front matter 973doi:10.1016/j.jcrs.2008.12.049

mailto:[email protected]

mailto:[email protected]

974 TECHNIQUE: NEW TRIPLE PROCEDURE

Figure 1. Top left: Preoperative photo-graph showing PBK with an AC IOLin situ. Top right: Femtosecond laser–created top-hat configuration. Bottomleft: Femtosecond–assisted top-hat con-figuration showing the predictable anduniform wound formation. Bottomright: Inferior straight sclerotomymade with an 18-gauge needle 1.5 mmfrom the limbus under the existingscleral flaps. Note the diametricallyopposite scleral flaps.

AC IOL. The unique benefits of femtosecond laser anda ‘‘glued IOL’’ could be adjunctive and provide en-hanced results in cases having PKP and IOL exchange.

SURGICAL TECHNIQUE

Femtosecond-Assisted Donor And Host Preparation

The initial part of the surgery is done at the femto-second laser facility. Donor buttons are preparedfrom whole globes. After the suction ring is appliedand adequate vacuum and centration are achieved,a top-hat configuration is created using a 60 kHz fem-tosecond laser (IntraLase FS [IntraLase Corp.]) (Fig-ure 1, top right, bottom left). For the host cut, thepatient is given topical anesthesia. After the suctionring is applied and adequate vacuum and centrationare achieved, a top-hat configuration is created. Thedonor cornea and patient are then moved to the kera-toplasty operating room.

Combined Keratoplasty and IOL Exchangewith Modification for the Glued IOL

The rest of the surgery is performedunder peribulbaranesthesia.A limitedperitomy is done in the inferotem-poral and superonasal areas 180 degrees apart, anda 3.0 mm � 3.0 mm area is marked on the sclera. Twopartial-thickness limbal-based scleral flaps of 3.0 mmare created.Twostraight sclerotomies, one slightly infe-rior to the other, are made with an 18-gauge needle1.5 mm from the limbus under the existing scleral flaps(Figure 1, bottom right). The top hat is inspected for

J CATARACT REFRACT SU

completeness. After the host button is removed, theAC IOL is explanted (Figure 2, bottom left). Limitedopen-sky anterior vitrectomy is then performed.

A posterior chamber 6.5 mm IOL is held witha McPherson forceps at the pupillary plane with onehand. An end-gripping 25-gauge microcapsulorhexisforceps (MicroSurgical Technology) is passed throughthe inferior sclerotomy with the other hand. The tip ofthe leading haptic is grasped with the microcapsulo-rhexis forceps and pulled through the inferior scleroto-my following the haptic curve (Figure 2, bottom right).The haptic is then externalized under the inferior scleralflap (Figure 3, top left). The trailinghaptic is also external-ized through the superior sclerotomy under the scleralflap (Figure 3, top right). After both haptics have been ex-ternalized, the graft is placed and cardinal sutures areapplied (Figure 3, bottom left). With a 22-gauge needle,a scleral tunnel is created along the curve of the external-ized haptic at the edge of the scleral bed of the flap (Fig-ure 3, bottom right). The haptic is tucked into this tunnel(Figure 4, top left; higher magnification, Figure 4, topright). A similar tunnel is created in the complimentaryarea on the other side, and tucking is performed. Fibringlue (Tisseel, Baxter) is reconstituted from a pack con-taining freeze-dried human fibrinogen, freeze-driedhuman thrombin, and aprotinin solution. The reconsti-tuted fibrin glue is injected through the cannula of thedouble syringe delivery system under the superior andinferior scleral flaps (Figure 4, bottom left). Local pressureis applied to the flaps for 30 seconds to allow polypep-tide formation. The same glue is applied in the area

RG - VOL 35, JUNE 2009

975TECHNIQUE: NEW TRIPLE PROCEDURE

between the sutures at the entire graft–host junction(Figure 4, bottom right). The conjunctiva is also apposedwith the glue.

Postoperatively, gatifloxacin eyedrops are pre-scribed 4 times a day, prednisolone acetate 6 timesa day, homatropine sulfate 3 times a day, and preser-vative-free tear substitutes 6 times a day.

Results

The triple procedure was performed in 3 patientswith PBK with AC IOL (Table 1). The mean age ofthe patients at presentation was 46 years. The preoper-ative best corrected visual acuity (BCVA) was lightperception, counting fingers, and counting fingers.Top-hat configuration was sculpted, with the donor

Figure 2. Top left: Augmentation of thetop-hat configuration in areas that hadpoor laser penetration because of over-lying opacity.Top right: Posterior uncuttissue dissectedwith a Vannas scissors.Bottom left: Explantation of the AC IOLafter removal of the host button. Bottomright: Leading haptic grasped with themicrocapsulorhexis forceps for beingpulled through the inferior sclerotomyfollowing the haptic curve.

Figure 3. Top left: Leading haptic exter-nalized completely under the inferiorscleral flap. Top right: The trailing hap-tic externalized through the superiorsclerotomy under the scleral flap. Bot-tom left: The graft button placed andcardinal sutures applied. Bottom right:Scleral tunnel created along the curveof the externalized haptic in the super-onasal area at the edge of the scleralbed of the flap.

J CATARACT REFRACT SURG - VOL 35, JUNE 2009


graft oversized by 0.2 mm in all 3 cases. The femtosec-ond laser parameters for the donor and lenticule prep-aration are shown in Table 2.

The immediate postoperative course was unevent-ful, and the BCVA had improved to counting fingers,6/12, 6/9, respectively, at the 1-month follow-up. The

Figure 4. Top left: The superior haptictucked into the superonasal tunnel.Top right: The tucking shown at highermagnification. Bottom left: Reconsti-tuted fibrin glue injected through thecannula of the double syringe deliverysystem under the inferior scleral flap.Bottom right: The glue applied at thegraft–host junction.

Table 1. Characteristics of the 3 patients.

Characteristic Patient 1 Patient 2 Patient 3

Age, y/sex 75/ F 25/M 35/MDiagnosis PBK with AC IOL PBK with AC IOL PBK with AC IOLSystemic problems None None NoneOcular problems None Conjunctival scarring

with narrow palpebralaperture (secondary to

viral illness)

None

PreopBCVA LP CF CFCorneal thickness (mm) 648 622 630Applanation IOP (mm Hg) 24 16 18

AL on A-scan (mm) 22.6 24.3 23.2Explanted IOL AC IOL AC IOL AC IOLPostop

BCVA (4 mo) CF 6/12 6/9Applanation IOP (mm Hg) 18 12 14

Implanted IOL PC IOL (6.5 mm optic,13.5 mm overall diameter)

PC IOL (6.5 mm optic,13.5 mm overall diameter)

PC IOL (6.5 mm optic,13.5 mm overall diameter)

Implanted IOL power (D) C22.5 C18.0 C21.0Intraop and postop complications None Preexisting fornix scarring;

required canthotomyfor suction ring placement

None

AC IOL Z anterior chamber intraocular lens; BCVA Z best corrected visual acuity; CF Z counting fingers; LP Z light perception; PC IOL Z posterior chamberintraocular lens; PBK with AC IOL Z pseudophakic bullous keratopathy with AC IOL

J CATARACT REFRACT SURG - VOL 35, JUNE 2009


Table 2. Femtosecond laser parameters for the 3 donors and recipients.

Parameter Donor 1 Recipient 1 Donor 2 Recipient 2 Donor 3 Recipient 3

Lamellar cutDepth (mm) 275 275 275 275 275 275Outer diameter (mm) 7.8 7.6 8.8 8.6 8.4 8.2Inner diameter (mm) 6.1 5.9 7.1 6.9 6.7 6.5Lamellar energy (mJ) 1.40 1.40 1.40 1.40 1.40 1.40Tangential spot separation (mJ) 5 5 5 5 5 5Radial spot separation (mJ) 5 5 5 5 5 5

Anterior side cutPosterior depth (mm) 305 305 305 305 305 305Anterior diameter (mm) 6.2 6.0 7.2 7.0 6.4 6.2Anterior energy (mJ) 1.45 1.45 1.45 1.45 1.45 1.45Anterior side-cut angle 90 90 90 90 90 90Anterior side-cut spot separation (mm) 2 2 2 2 2 2Anterior side-cut layer separation (mm) 2 2 2 2 2 2

Posterior side cutAnterior depth (mm) 245 245 245 245 245 245Posterior diameter (mm) 7.7 7.5 8.7 8.5 8.7 8.5Posterior energy (mJ) 1.45 1.45 1.45 1.45 1.45 1.45Posterior depth (mm) 1200 500 1200 500 1200 500Posterior side-cut angle 90 90 90 90 90 90Posterior side-cut spot separation (mm) 2 2 2 2 2 2Posterior side-cut layer separation (mm) 2 2 2 2 2 2

first case had prexisting advanced glaucoma with tra-beculotomy; the BCVAdid not improvemuch after theprocedure. At the 4-month follow-up, all 3 patientsmaintained the 1-month BCVA. There were noepisodes of keratoplasty-related problems (infection,rejection, dehiscence) or IOL-related problems (vitre-ous incarceration, endophthalmitis, subluxation,haptic extrusion).

DISCUSSION

In PKP cases, all attempts should bemade to minimizeendothelial cell loss in the intraoperative and postop-erative periods. To provide the maximum number ofendothelial cells to the host, there may be a tendencytoward larger grafts in conventional keratoplasty forbullous keratopathy. However, this is associatedwith an increased epithelial cell load, which is proba-bly associated with a higher risk for graft rejection.19,20

Since a top-hat configuration is larger at the inner end,it provides a greater number of endothelial cells for thesame number of epithelial cells. In addition, with thetop-hat configuration, smaller outer sizes can be pre-pared and the graft–host junction can be farther fromthe limbus centripetally, reducing chances of neovas-cularization. These 2 unique advantages of the top-hat configuration may enhance graft survival byreducing chances of graft rejection and promoting en-dothelial survival.


We noted an incomplete cut in one case (patient 2),whichwas completed bymanual dissection. However,the partial cuts created by the femtosecond laser actedas a template for lamellar separation. In future, withincreased penetration and better laser mechanics, themore challenging scarred cornea might also be suc-cessfully sculpted.

Intraocular lens exchange is arguably the more chal-lenging step in this surgery. The safety and long-termefficacy of a transsclerally sutured PC IOL are less thansatisfactory.12–14 The transsclerally sutured IOL is as-sociated with a steep learning curve and requires spe-cial steps that an anterior segment surgeon may notuse routinely. In a previous study,12 ultrasound biomi-croscopy showed that transscleral suturing of an IOLhad problems related to accurate suturing at the ciliarysulcus. In addition, there are issues with IOL iris con-tact, pigment dispersion, high aqueous flare, and vitre-ous incarceration.

In PKP, the conventional wisdom is to reduce the‘‘open-sky’’ duration to as short a time as possible asthere is an associated risk for expulsive hemorrhageor choroidal effusion. The tamponade effect of a se-curely fixated IOL can be helpful in the duration be-tween completion of host dissection and suturing ofthe donor button (the open-sky period). Transscleralsuture fixation requires adjustment of the suturesand knots to maintain the IOL in position, leading to



Figure 5. Diagram showing biomechanical and kineticproperties of manual keratoplasty with transscleral su-ture-fixated PC IOL (TSF IOL) (top) and femtosecond-as-sisted keratoplasty (FAK) with glued IOL (bottom).Differences between the 2 approaches are indicated bythe points. Point 1, top: Haptic–suture junction in theTSF IOL, with the IOL hanging like a hammock. Point1, bottom: Rigid PMMA haptic in glued IOL fixatedwith the sclera. Point 2, top: Transverse graft–host junc-tion. Point 2, bottom: More stable top-hat configuration.Point 3, top: Size of epithelial side (outer cut) same asthat of endothelial side (inner cut). Point 3, bottom: Sizeof epithelial side (outer cut) less than that of endothelialside (inner cut), leading to greater number of endothelialcells for smaller epithelial load and placement of suturesfarther from limbus. Point 4, top: Knots in TSF IOL maydegrade and slip. Point 4, bottom: Haptic is securelytucked and sealed with fibrin glue in glued IOL. Point5, top: More pseudophacodonesis with TSF IOL. Point5, bottom: Less pseudophacodonesis with glued IOL.

a delay in placement of the donor button. It also re-quires a special IOL with eye haptics and may not bereadily available.

An open-sky procedure is often associated with an-terior vitrectomy. The resultant hypotony makes su-ture placement and adjustment difficult. In an open-sky procedure with a deficient posterior capsule,there is no tamponade effect and the results can bedisastrous if the patient strains or coughs. The aimof the surgeon in this scenario should be to reducethe surgical time. Most of the time consumption inthese cases is in passing the straight needle and ty-ing and adjusting the sutures. A glued IOL can beused as a safe and effective alternative. The newtechnique has a short learning curve. Most steps, ex-cept externalization and tucking, are part of routineanterior segment procedures.18 There is no require-ment for an extra set of sutures and a straight nee-dle, which can be difficult to pass in a hypotonousopen globe.

While doing scleral fixation with sutures, the sur-geon must readjust the knots to maintain the centralposition of the IOL. In our procedure, simply manipu-lating the amount of externalization can cause propercentration of the IOL. The final tucking of the hapticprovides further stabilization.

A sutured scleral-fixated IOL hangs in the posteriorchamber, with the sutures passing through the hapticeyes, similar to a hammock, causing dynamic torsionaland anteroposterior oscillation. This pseudophacodo-nesis may result in progressive endothelial loss. How-ever, in our technique, rigid haptics are used forfixation on the scleral side and the stable optic–haptic


junction prevents torsional and anteroposterior insta-bility. Therefore, there is much less pseudophacodone-sis (Figure 5).

The haptics are covered in the scleral flap andtucked well inside the scleral pocket. There is an addi-tional well-apposed layer of conjunctiva over thesclera. This further reduces the chances of hapticextrusion.

Femtosecond laser–assisted keratoplasty with top-hat configuration and a glued IOL provides a uniquesolution in cases with bullous keratopathy and ACIOLs. This is an improvement over the traditional tech-nique of manual trephination and transscleral suturefixation of the IOL (Figure 5). The femtosecond laser’stop-hat configuration provides a greater number of en-dothelial cells in the donor lenticule and a more stablewound configuration. Better dynamic stability of theglued IOL prevents pseudophacodonesis and may re-duce endothelial cell loss or repositioning surgery.Combined, these 2 surgical modalities may improveresults. Although our initial results with this techniqueare good, larger comparative trials to evaluate thelong-term outcome of the technique with that of man-ual trephination with a transscleral suture-fixated IOLwill provide more conclusive evidence.

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femtosecond-assisted keratoplasty with fibrin glue–assisted sutureless posterior chamber lens...

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