Concomitant sutureless scleral fixation of intraocular lens with keratoplasty: Review of surgical techniques.

Sutureless scleral fixation of intraocular lens (sSFIOL) is a commonly employed method of optical rehabilitation of aphakic patients with deficient capsular support, and corneal transplant surgeries can be simultaneously combined with sSFIOL to handle aphakic corneal opacities. A single-stage procedure circumvents the need for repeat intraocular procedures and carries lower risk of graft endothelial damage, endophthalmitis, and macular edema associated with sequential surgeries. However, it mandates surgical expertise and increases the chances of postoperative inflammation. A basket of options is available with the corneal surgeons regarding the manner of host and donor preparation as well as the approaches to scleral fixation and certain intraoperative modifications along with postoperative vigilance may enhance the surgical outcomes. Most of the studies pertaining to keratoplasty with sSFIOL categorize to case reports/series, surgical techniques, and retrospective studies with very limited prospective data available currently. The purpose of the present review is to consolidate all available literature on concomitant sSFIOLs and keratoplasty procedures.

Intraoperative optical coherence tomography-guided donor corneal tissue assessment and preparation.

Purpose: To evaluate the role of intraoperative optical coherence tomography (i-OCT) in donor grading, selection, and preparation during different types of keratoplasty. Methods: Seventy-one consecutive donor corneas collected over 6 months, after clinical grading, were observed by an experienced corneal surgeon under an i-OCT equipped microscope. The donor preparation (manual/automated) for different types of keratoplasty procedures was also undertaken under i-OCT. Results: The mean central corneal thickness of optical and nonoptical grade tissues was 533 ± 19 and 662 ± 52 µm, respectively. The i-OCT-based grading matched with clinical grading in 98.5% cases. Irregular thickness, anterior stromal hyperreflectivity, and previous scars were appreciated in 1.4, 1.4, and 7.04% donors, respectively. During Descemet stripping automated endothelial keratoplasty, i-OCT facilitated selection of appropriate microkeratome head for automated donor preparation in all cases, besides allowing manual dissection of partially dissected lenticule, identification of site of inadvertent perforation, and eccentric trephination in one case each. During Descemet membrane endothelial keratoplasty, i-OCT-based assessment of preexisting scar (five cases) guided careful tissue selection (2/5) and preparation. During predescemetic endothelial keratoplasty, precise needle advancement allowed successful type-1 bubble formation in all cases. All manually punched donors demonstrated an extra endothelial ledge, while those with automated preparation showed tapering donor margins. Conclusion: i-OCT might serve as a useful imaging tool for objective assessment of donor characteristics. The modality may complement clinical evaluation for donor grading, selection, and preparation.

Surgical outcomes of concomitantly performed penetrating keratoplasty with intrascleral haptic fixation.

PURPOSE: : To describe the surgical results of concomitantly performed optical penetrating keratoplasty (PKP) with glued intrascleral haptic fixation (ISHF). METHODS: : Retrospective review of 18 patients (15-72 years) with best-corrected visual acuity (BCVA) of ≤1/60 subjected to unilateral concomitant optical PKP with ISHF and followed up for 13.11 ± 5.83 months (6-26 months) was undertaken. RESULTS: : The most common diagnoses were failed PKP (9/18, 50%) followed by aphakic bullous keratopathy (5/18, 27%). Preoperative glaucoma, peripheral anterior synechiae (PAS), and deep vascularization were present in 7/18 (38.88%), 12/18 (61.11%), and 5/18 (27.77%) patients, respectively. Intraoperatively, concomitant procedures such as pupilloplasty and intraocular lens explant were undertaken in 5/18 (27.277%) patients and 1/18 patients (5.55%) experienced suprachoroidal hemorrhage. At final follow-up, BCVA was ≥6/60 in 50% patients (mean astigmatism: 4.79 ± 1.68D), and 55.55% cases experienced graft failure (90% failed within one year of surgery). The most common causes of graft failure were glaucoma (50%), glaucoma with rejection (20%), rejection (10%), retinal detachment (10%), and suprachoroidal hemorrhage (10%). The ODDS ratio (OR) of having graft failure with the following factors was postoperative secondary interventions (OR: 6), postoperative complications (OR: 2.25), prior failed graft (OR: 1.8), preoperative PAS (OR: 1.75), intraoperative concomitant procedures (OR: 1.5), preoperative glaucoma (OR: 1.33), previous surgeries (OR: 1.24), and deep corneal vessels (OR: 0.66). CONCLUSION: : All patients underlying PKP combined with glued ISHF must be counseled about suboptimal surgical outcomes. Emphasis is laid on appropriate case selection and stringent follow-up during the first year after surgery. Secondary interventions should be undertaken cautiously and judiciously in these patients.