Combine and Conquer Combining sutureless lamellar keratoplasty, phacoemulsification, and IOL implantation in one surgery allows rapid visual rehabilitation in patients with cataract and corneal opacity By Tushar Agarwal and Pooja Bandivadekar

At a Glance Phacoemulsification in patients with corneal opacity can be a challenge – patients with central but superficial opacity and concomitant cataract are common, yet do not typically require a full-thickness transplant

Conventional lamellar keratoplasty has issues, too – problems such as infection and suture-related astigmatism can make outcomes unpredictable

The use of biological glue to adhere the graft to the host cornea can bypass the problem of sutures, and has seen success when performed as a standalone procedure for treating corneal opacity

Combining cataract surgery with automated sutureless anterior lamellar keratoplasty can provide rapid vision rehabilitation, and make phacoemulsification more straightforward for the surgeon

Performing phacoemulsification in a patient with corneal opacity is a challenge, even for an experienced cataract surgeon. Often, we come across patients with central but superficial opacities, and concomitant cataract, who do not warrant a full thickness keratoplasty. One option for these patients is a combined surgery, with a lamellar graft and phacoemulsification. However, conventional lamellar keratoplasty has its own problems, such as suture-related astigmatism and infections, and can be unpredictable.

But there is a way to bypass the problem of sutures – using a biological glue to stick the graft to the host cornea. The results we have witnessed so far of sutureless lamellar keratoplasty, performed as a standalone procedure for the management of corneal opacities, have been encouraging (see Figure 1).

Figure 1. Sutureless anterior lamellar keratoplasty for the management of corneal opacity has returned promising results. (left) Preoperative eye (right) Postoperative eye.

The why and the how

We decided to combine cataract surgery with microkeratome-assisted sutureless anterior lamellar keratoplasty in eyes with visually significant corneal opacity involving less than 200 µm of anterior stroma. This approach enables rapid visual rehabilitation after a single combined surgery (rather than a staged procedure). The residual stromal bed is thick and smooth – which means performing phacoemulsification is less surgically challenging.

In terms of technique, sutureless corneal transplantation can best be described as replacing the 'free LASIK cap', with the cap being taken from a donor cornea.

We performed this triple procedure (lamellar keratoplasty, phacoemulsification and IOL implant) in seven eyes of six patients with anterior stromal corneal opacity. All the procedures were carried out under peribulbar anesthesia, and a Moria microkeratome and artificial chamber (ALK System, Moria) with a 200 µm microkeratome head. For trephination of the host cornea, a suction ring (number 0) was placed over the host cornea, and the same microkeratome head (200 µm) was used to trephine the recipient bed. Phacoemulsification was completed through a 2.7 mm superior incision, and the donor lenticule was then placed on the host bed and any residual fluid from the groove at the graft-host junction was absorbed using merocel sponges. One drop of slow component (thrombin 4) fibrin sealant (Tisseel, Baxter Healthcare) was evenly spread along the edges of the donor cornea, into the groove. No adhesive was applied over the stromal bed. The glue was allowed to act for a period of three minutes, and following this, any excess coagulated glue was removed using the sponge wick. A bandage contact lens was then placed over the cornea and retained for a period of three weeks.

"We have found this surgery to be easily repeatable, with consistent results, and we believe that the fast visual rehabilitation it offers will result in its widespread adoption in the future."

Better together?

The results were promising. Mean topographic and refractive astigmatism were 2.77 ± 2.6 D and 1 ± 0.65 D, respectively at six months of follow-up. The mean spherical equivalent was -0.7 ± 1.31 D, with a range of -2 D to +1.38 D. Owing to irregular corneal surface and haze, the pre-operative keratometry and refraction could not be assessed