Sequential Versus Combined Penetrating Keratoplasty and Cataract Surgery

Development of a Web-Based Algorithm for Understanding the Intraocular Lens-Based Surgery in Stable and Progressing Keratoconus for Non-Specialist Ophthalmologists

PURPOSE

To propose an algorithm to facilitate lens-based surgery in keratoconus.

METHODS

A literature review was performed to prepare a software algorithm based on cone location, stability, best spectacle-corrected distance visual acuity (BSCVA) level and whether there is a clear or cataractous lens. The software usability was assessed through a 10-question questionnaire and two hypothetical keratoconus case histories (moderately simple and moderately complex) given to 15 trainees. The usability questionnaires were graded on a Likert scale (1 = strongly disagree to 5 = strongly agree) and two case histories (1 = very difficult to 7 = very easy).

RESULTS

The algorithm can be found at https://www.sussexeyelaserclinic.co.uk/keratoconus/. Thirteen trainees completed the questionnaire. 91.9% would frequently use it; for 100%, it was easy to use independently without technical support; for 63.7%, it was strongly integrated; for 100%, it was consistent; 100% thought that most people would learn to use it quickly, 91.9% found the system not cumbersome to use, felt very confident to use it and need not learn a lot to use it. The first case was found easy by 63.7% and the second by 45%.

CONCLUSION

We present an algorithm as a guide for lens-based surgery in stable and progressing keratoconus, which is classified based on cone location. This algorithm will help trainee and "non-specialist" ophthalmic surgeons understand the pre-operative planning for the surgery and referral to the "specialist" corneal surgeon, considering factors such as progression, BSCVA, keratometry, topography and apex location of the cone in keratoconus patients.

Complete anterior segment reconstruction: Corneal transplantation and implantation of an iris prosthesis and IOL in a single surgery

PURPOSE

Patients who have suffered an ocular trauma may present with varying degrees of injury to the anterior segment. In this retrospective interventional case series, we report the outcome of seven patients who underwent complete anterior segment reconstruction in a single surgery.

METHODS

All patients with posttraumatic corneal decompensation or scar, aphakia, and iris defect underwent human donor corneal graft transplantation and implantation of an intraocular lens combined with a flexible silicone iris prosthesis. Postoperative examinations included assessment of best corrected distance visual acuity, objective refraction, and intraocular pressure. Sensitivity to glare and subjective discontent with the eye's appearance was rated on a scale from 1 to 10, with 1 standing for low and 10 for high severity.

RESULTS

Mean best corrected distance visual acuity (BCDVA) was 1.51 ± 0.26 logMAR preoperatively and 1.29 ± 0.36 logMAR postoperatively. Mean IOP was 15.71 ± 8.94 mmHg pre-surgery and 13.57 ± 6.52 mmHg post-surgery. The mean sensitivity to glare was reduced from 7.17 ± 2.91 to 3.80 ± 3.43 and subjective cosmetic disfigurement was reduced from 5.33 ± 3.35 to 1.80 ± 1.60.

CONCLUSIONS

A single surgery technique for entire anterior segment reconstruction in trauma patients can effectively reduce glare and patient discontent with the eye's appearance.

Corneal Pathology and Cataract: Combined Surgery or Sequential Surgery?

Objectives

To compare our combined surgery (CS) and sequential surgery (SS) results.

Materials and Methods

The files of 44 patients who underwent CS (penetrating keratoplasty [PK], cataract extraction, and intraocular lens [IOL] implantation) and 126 patients who underwent SS (cataract extraction and IOL implantation in a second session after PK) between January 2009 and December 2018 were evaluated retrospectively. One eye of the patients who were followed up for at least 1 year was included in the study. The two groups were compared in terms of indications, corrected distance visual acuity (CDVA), refractive results, complications, and graft survival.

Results

In the CS and SS groups, the median age was 63 (30-79) and 43 (18-73) years (p<0.001) and the median follow-up time was 51 (13-152) and 64.5 (13-154) months (p=0.011), respectively. The most common PK indications were traumatic corneal scar (20.5%) and endothelial dystrophy (15.9%) in the CS group versus keratoconus (24.6%) and stroma dystrophy (17.5%) in the SS group. In the CS and SS groups, 50% vs 69% of patients had CDVA ≥0.4 (p=0.04); 45.5% vs 25.4% had CDVA (0.1-0.3) (p=0.04); and 54.5% vs 73% had spherical equivalent ≤±2.0 D (p=0.02). The most common postoperative complications were glaucoma (20.5% vs 15.9%, p=0.48) and allograft reaction (9.1% vs 23%, p=0.04). Graft survival rates were 95.2% vs 86.5% (p=0.10) at 1 year and 75.9% vs 68.9% (p=0.47) at 5 years, respectively.

Conclusion

Over long-term follow-up, the groups were similar in terms of graft survival. For this reason, each patient must be evaluated separately whether to perform a combined or sequential surgery. Given the lower refractive error and higher expectation of final visual acuity, SS can be more advantageous especially in young patients.

Long-term Results of a Combined Procedure of Cataract Surgery and Descemet Membrane Endothelial Keratoplasty With Stromal Rim

PURPOSE

To evaluate the long-term results of combining cataract surgery, intraocular lens (IOL) implantation, and Descemet membrane endothelial keratoplasty with peripheral stromal support (DMEK-S).

METHODS

The outcomes of 107 eyes of 37 patients who had undergone a combination of cataract surgery, IOL implantation, and DMEK-S between October 2007 and February 2015 were retrospectively evaluated. The average follow-up duration was 18.2 ± 18.3 months (range, 6-84 months). Changes in uncorrected and corrected distance visual acuity, spherical equivalent, and corneal endothelial cell density were analyzed. Intraoperative and postoperative complications were also recorded.

RESULTS

The mean logMAR uncorrected distance visual acuity improved from 0.92 ± 0.60 preoperatively to 0.33 ± 0.33, 0.28 ± 0.25, 0.24 ± 0.20, and 0.27 ± 0.27 at 6, 12, 24, and 36 months postoperatively (P < 0.001), respectively. The mean logMAR corrected distance visual acuity improved from 0.62 ± 0.65 preoperatively to 0.17 ± 0.29, 0.13 ± 0.21, 0.07 ± 0.16, and 0.11 ± 0.23 at 6, 12, 24, and 36 months postoperatively (P < 0.001), respectively. The mean endothelial cell density decreases were 50.7% ± 21.1%, 50.8% ± 19.8%, 60.7% ± 16.6%, 62.2% ± 11.8%, and 61.8% ± 20.0% at 6, 12, 24, 36, and 48 months after surgery, respectively. Similar trends, although with slightly better visual outcomes, were found in the subgroup of patients without other eye diseases. The mean final deviation from intended spherical equivalent was 0.77 ± 1.19 D, representing a hyperopic shift.

CONCLUSIONS

A combined procedure of cataract surgery, IOL implantation, and DMEK-S is an effective method of treatment in patients with combined corneal disease and cataract, maintaining visual rehabilitation in the long term. Future developments should be performed to minimize the incidence of complications.

Evaluation of an interlaced triple procedure: penetrating keratoplasty, extracapsular cataract extraction, and nonopen-sky intraocular lens implantation

To evaluate an interlaced triple procedure that involved penetrating keratoplasty (PKP), extracapsular cataract extraction (ECCE) using diathermy capsulotomy, and nonopen-sky intraocular lens (IOL) implantation.This retrospective study involved data from 34 patients who were diagnosed with severe corneal opacities and cataracts. These patients were divided into an interlaced procedure group (21 patients) and a traditional procedure group (13 patients). In the interlaced group, the method of continuous curvilinear capsulorhexis (CCC) was completed via diathermy capsulotomy. The donor corneal button was sutured at 8 positions (at equal intervals) using 10-0 nylon sutures, and the IOL was inserted into the capsular bag using a closed anterior chamber approach at the 10:30 to 12 o'clock positions between the sutures. In the traditional group, CCC was completed using side-port capsular forceps, and the IOL was implanted using an open anterior chamber approach.In the interlaced group, the CCC, open-sky, and total operation times were significantly shorter than in the traditional group (P < .05). Neither the best-corrected visual acuity (BCVA) nor corneal endothelial cell density was significantly different between the groups at 1 and 6 months after the operation.This interlaced triple procedure for the treatment of corneal diseases with cataracts appears to be feasible and practical.

Graft survival and visual outcome after simultaneous penetrating keratoplasty and cataract extraction

AIM

To evaluate the indications, complications, and visual and graft survival outcomes in eyes that had undergone simultaneous cataract extraction and penetrating keratoplasty (PKP).

METHODS

We described a retrospective study of 101 patients who had undergone simultaneous cataract extraction and PKP at King Khaled Eye Specialist Hospital between January 1, 2001, and December 31, 2002. All patients were followed up postoperatively with maximum follow-up 68 months.

RESULTS

The mean age of patients was 61 years. The mean overall follow-up was 27 months. The most common indications for surgery were corneal scarring (45.5%), previous failed graft (15.8%), corneal ulcer (12.9%), Fuchs endothelial dystrophy (8.9%), stromal dystrophy (2.9%), and other conditions (14.5%). Overall, 69 grafts (68.3%) remained clear at final follow-up. Previous glaucoma or postoperative glaucoma had no statistically significant effects on graft outcome (P>0.05).The graft rejection rate (17.8%) was a significant risk factor for failure (P=0.00). Age, gender, indications for surgery, corneal graft diameter, and intraoperative vitreous loss had no statistically significant effects on the PKP outcome (P>0.05). Postoperative visual acuity was significantly associated with preoperative visual acuity (P<0.01).

CONCLUSION

The present study provides evidence that performing a combined procedure results in more rapid visual rehabilitation and good graft clarity.

Intrastromal corneal ring segments: effect of relationship between alignment and topographic keratometric meridians

PURPOSE

To determine whether the keratometric and refractive surgical effects of paired intrastromal corneal ring segments (ICRS) depend on their alignment relative to steep and flat topographic meridians.

SETTING

St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.

DESIGN

Comparative case series.

METHODS

Keratoconic patients who had two 0.3 mm Intacs ICRS inserted were retrospectively grouped depending on alignment of segments within 30 degrees either side of the steep (meridional group) or the flat (perpendicular group) topographic meridians, respectively, with the rest in the oblique group. Principal outcome measures were changes in visual acuity, refractive surgical effect, and keratometric surgical effect 4 months postoperatively.

RESULTS

Forty eyes of 40 patients were included. There was a significant reduction in keratometric power (flattening) (P<.01) but not in refractive error in all 3 groups. The reduction in keratometric astigmatism was significantly greater in the perpendicular group (-2.67 diopters [D]) than in the meridional group (-0.65 D) (P=.03), with the oblique group (-0.9 D) in between (P=.12). The principal reduction was flattening orthogonal to the incision site, with relative steepening in the axis of ICRS alignment. In all groups, variations in the refractive surgical effect and keratometric surgical effect were very high.

CONCLUSIONS

Placement of two 0.3 mm ICRS had a variable effect with limited predictability. There was predominant flattening of the cornea orthogonal to the axis of ICRS alignment. Irrespective of the location of preoperative steep and flat keratometric meridians, the maximum reduction in astigmatism occurred when the incision and the segments were placed along the flat topographic meridian.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.