TECHNIQUE

Scleral fixation of intraocular lenses combined

with penetrating keratoplasty
Fahad A. Al-Qahtani, MD

I describe a technique for transscleral fixation of a posterior chamber intraocular lens (PC IOL)
combined with penetrating keratoplasty. Partial-thickness trephination of the cornea is followed
by full-thickness penetration of the anterior chamber at 12 o’clock and 6 o’clock through 5.5 and
2.0 mm incisions, respectively. Scleral fixation of a PC IOL is performed through the incisions under
a closed chamber followed by replacement of the diseased graft with a donor button. The results in
5 eyes of 5 patients with aphakic bullous keratopathy and lack of capsule support are reported.
Financial Disclosure: The author has no financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2010; 36:373–376 Q 2010 ASCRS and ESCRS
Online Video

Many cases in which penetrating keratoplasty (PKP) is processes come in contact with the posterior surface
indicated involve aphakic and pseudophakic bullous of the iris. This carries the risk for the needle to pass
keratopathy.1 In aphakic patients with lack of capsule through the ciliary processes or even the pars plana.5
support who require keratoplasty, there are 3 options In addition, the open-sky technique is associated
for intraocular lens (IOL) implantation: an anterior with an increased risk for vitreous loss, choroidal
chamber IOL (AC IOL) or iris suture or transscleral su- detachment, and expulsive hemorrhage.6 Scleral
ture fixation of a posterior chamber IOL (PC IOL). The collapse, which makes the surgery more lengthy and
3 techniques have been described in case series, and hazardous, is an additional risk. I describe a surgical
various aspects such as safety and reproducibility technique for IOL implantation that uses transscleral
have been compared.2 suture fixation in a closed chamber combined with
Although the use of an angle-supported anterior PKP for patients with corneal opacities associated
chamber IOL during PKP requires shorter operating with aphakia and a lack of capsule support.
time than a suture-fixation technique, suture fixation
of a PC IOL is preferred by most authors because of SURGICAL TECHNIQUE
the smaller risk for glaucoma, graft failure, macular
edema, and other complications.3,4 An important factor Two 5.0 mm conjunctival periotomies are fashioned at
in attaining sulcus fixation is entering the eye while it is the 10 o’clock and 4 o’clock positions (left eye) or the 2
closed. In all case series describing suture fixation of o’clock and 8 o’clock positions (right eye) followed by
a PC IOL combined with PKP, the surgery has been per- dissection of 2 half-thickness 1.0 to 2.0 mm wide
formed under an open-sky approach.2 triangular scleral flaps at the limbus. Partial-thickness
I believe that the open-sky approach may be less safe trephination of the cornea is performed, and the ante-
for several reasons. When the globe is open and hypo- rior chamber is entered through superior and inferior
tensive, the ciliary sulcus collapses so the ciliary corneal incisions measuring 5.5 mm and 2.0 mm
made at 12 o’clock and 6 o’clock, respectively, using
a superblade (Figure 1). Anterior vitrectomy is per-
Submitted: May 23, 2009. formed if necessary.
Final revision submitted: September 12, 2009. A double-armed 10-0 polypropylene suture (Pro-
Accepted: September 28, 2009. lene, Ethicon Inc.) on straight needles is cut in half.
The suture end of each half is tied to the haptics of
From the Department of Ophthalmology, Hamad Medical Corpora- a 5.0 mm poly(methyl methacrylate) (PMMA) IOL. Al-
tion, Doha, Qatar.
though it requires a larger incision, a rigid PMMA IOL
Corresponding author: Fahad A. Al-Qahtani, MD, Post Office Box might cause less trauma at the graft–host interface
14422, Doha, Qatar. E-mail: [email protected]. during insertion than a folded IOL. One straight

Q 2010 ASCRS and ESCRS 0886-3350/10/$dsee front matter 373

Published by Elsevier Inc. doi:10.1016/j.jcrs.2009.09.041
374 TECHNIQUE: COMBINED PENETRATING KERATOPLASTY AND SCLERAL FIXATION OF IOL

Figure 1. A: Two triangular scleral flaps are dissected at 4 o’clock and 10 o’clock. B, C: Partial thickness trephination of the cornea. D: Penetration
of the anterior chamber through a 5.0 mm corneal incision at 12 o’clock and a 2.0 mm incision at 6 o’clock.

needle is passed through the superior corneal incision corneal button is placed on a Teflon block endothelial
with the suture end exiting through the inferior side up and cut with a trephine 0.5 mm larger than the
corneal incision. The needle is then passed through recipient bed. Finally, the recipient corneal button is
the inferior corneal incision behind the iris, exiting removed with right and left corneal scissors. The do-
into the superior scleral bed 1.5 mm from the limbus. nor corneal button is placed and sutured with 16 inter-
The other needle is passed directly from the superior rupted 10-0 nylon sutures. Postoperatively, patients
corneal incision, exiting through the inferior scleral receive combined antibiotic–steroid eyedrops and
bed. The superior incision is widened using a corneal ointment (Video).
scissors, and the IOL is introduced and positioned be-
hind the iris after an ophthalmic viscosurgical device
(OVD) (sodium hyaluronate) is injected into the ante- Results
rior chamber .The sutures are pulled tightly and tem- The combined technique was performed in 6 eyes of
porarily tied under the scleral flaps. After stable IOL 6 patients with aphakic bullous keratopathy and lack
centration is achieved, a surgeon’s knot is completed. of posterior capsule support who had PKP between
The scleral flap is then replaced to cover the polypro- December 2004 and September 2007. Informed con-
pylene knot with an 8-0 polyglactin suture (Vicryl, sent for participation was obtained from all patients.
Ethicon Inc.) and the overlying conjunctiva reapproxi- All surgery was performed by the same surgeon.
mated with the same suture material. Clinical characteristics of the patients are summa-
Donor tissue stored in McCarey-Kaufman medium rized in Table 1. All patients had detailed preoperative
is used within 48 hours of preservation. The donor and postoperative assessments, which included

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 TECHNIQUE: COMBINED PENETRATING KERATOPLASTY AND SCLERAL FIXATION OF IOL 375

through a separate paracentesis close to the limbus to

Table 1. Clinical characteristics of the 5 patients.
preserve the integrity of the graft–host interface.
Characteristic Value Postoperatively, the graft remained clear in all pa-
tients throughout the follow-up period. A corneal ulcer
Age (Y)
developed 1 month after surgery in Case 1 and was
Mean 54
Range 21–68
treated with lubricants and topical antibiotic agents;
Sex, n (%) the ulcer resolved in 5 days. Angiographic cystoid mac-
Female 3 (60) ular edema developed in Case 3, but the visual acuity
Male 2 (40) remained stable at 0.05 after 1 year. Glaucoma devel-
Time Since Cataract Surgery (Mo) oped in Cases 2 and 5, but the IOP was controlled on
Mean 18 a single antiglaucoma medication (beta-blocker). In
Range 3–42 the other 3 cases, the mean IOP dropped from 17.33
Duration of Follow-up (Mo) to 13.67 mm Hg at 12 months. There was no occurrence
Mean 32 of IOL decentration, graft rejection, or graft failure.
Range 15–48
The visual acuity improved in all cases (Table 2).
There was no difference in visual acuity between the
testing of corrected distance visual acuity, refraction, eye that required anterior vitrectomy during surgery
measurement of intraocular pressure (IOP), slitlamp and those that did not have vitrectomy.
examination, and fundoscopy or ultrasonography
depending on the media clarity. The condition of the
posterior capsule was assessed by slitlamp. In 2 cases DISCUSSION
in which the posterior capsule could not be visualized Scleral suture fixation of PC IOLs is often used in eyes
through the hazy cornea, ultrasound biomicroscopy of that lack capsule support. Table 3 reviews the results
the anterior segment was performed and the remnants of studies involving combined PKP and scleral fixation
of the capsule were insufficient for IOL support. Eyes of a PC IOL.7–11 In these studies, the procedure was
in which the corneal opacity would impede visualiza- performed as an open-sky technique.2 To my knowl-
tion of the needle passes as they entered below the iris edge, I describe the first results using a surgical
toward the ciliary sulcus were excluded from the technique that allows scleral fixation of PC IOLs in
study. Other exclusion criteria included glaucoma a closed chamber combined with PKP, avoiding the
and history of intraocular surgery other than cataract potential hazards of the open-sky technique.
extraction. Intraocular lens power was calculated us- One limitation of the technique is that it is suitable
ing the SRK II formula targeted for 1 to 2 diopters of only in cases in which the corneal opacity allows visu-
postoperative myopia. alization of the transscleral sutures as they pass
Intraoperative complications included hyphema beneath the iris. However, this requires only that the
that developed during scleral passes of the sutures in opacity opposite the scleral flaps is relatively clear; of
Case 2 and during synechiolysis in Case 5; in both the 6 cases reported, only 1 with a diffuse, dense cor-
cases, the hyphema was mild and was easily controlled neal opacity was excluded based on this criterion.
by injection of OVD. Vitreous prolapse occurred in Another potential limitation of the technique is the
Case 2, requiring an anterior vitrectomy before IOL possibility of inducing damage at the graft–host junc-
implantation. Anterior vitrectomy was performed tion as the IOL passes through the corneal incision.

Table 2. Preoperative and postoperative data of 5 patients.

Postop VA Postop IOP (mm Hg) Endothelial Cell Count (mm2)

Patient Preop VA At 6 Mo At 12 Mo Preop IOP (mm Hg) At 6 Mo At 12 Mo At 6 Mo At 12 Mo

1 0.05 0.3 0.2 18 14 14 1635 1650

2 0.03 0.1 0.2 15 16 13 1355 1405
3 0.03 0.05 0.05 19 12 14 1450 1470
4 0.06 0.3 0.1 16 28 14* 1535 1520
5 0.03 0.2 0.3 14 18* 16* 1490 1475
Mean 0.04 0.19 0.17 16.4 17.6 14.2 1493 1504

IOP Z intraocular pressure; VA Z visual acuity in decimal notation

*Intraocular pressure was controlled on a twice-daily beta-blocker.

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376 TECHNIQUE: COMBINED PENETRATING KERATOPLASTY AND SCLERAL FIXATION OF IOL

Table 3. Studies of combined keratoplasty with scleral fixation of PC IOL.

Study* Number of Eyes Effect on Visual Acuity Graft Clarity Glaucoma CME

Koçak-Altintas7 29 R20/400 in 86.2% 26(89.7%) clear, 3 failed 7 (24%) d

Kandarakis8 10 7 improved, 2 same, 1 worsened† 9 clear, 1 rejection 2 (20%) 2 (20%)
Jensen9 21 !0.1 in 23.8%, 0.10.33 in 66.7%, d Newly developed in d
O0.33 in 9.5%z 1 eye, worsened in 3
Hill10 36 R20/40 in 44.4% 2 failedx d 10 (27.8%)
R20/200 in 69.4%
Holland11 105 R20/40 in 27.6% d Newly developed in 10 (9.5%)
20/5020/200 in 35.2% 20 of 66 eyes (30.3%),
worsened in
12 of 39 eyes (30.8%)

CME Z cystoid macular edema; PC IOL Z posterior chamber intraocular lens

*First author
†
Visual acuity worsened as a result of graft rejection.
z
Visual acuity improved in 95% and remained the same in 5%.
x
One graft failed due to rejection and the other failed secondary to uncontrolled glaucoma.

Although no eye in this series experienced graft failure consequences for suture technique, implantation procedure,
or rejection, a larger series may be needed to exclude and choice of PCL design. Refract Corneal Surg 1993; 9:333–339
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retinal detachments and suprachoroidal hemorrhage procedures. J Cataract Refract Surg 2001; 27:1172–1175
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open-sky technique,11,12 but these complications plantation of scleral-sutured posterior chamber intraocular lenses
did not occur in my series. The postoperative visual during penetrating keratoplasty. J Refract Surg 2000; 16:456–458
8. Kandarakis AS, Doulas KG, Amariotakis AG. Penetrating kera-
acuity of the 5 patients ranged from 0.05 to 0.3, with toplasty and transsclerally suture-fixated intraocular lenses. J
the worst vision attributed to cystoid macular edema. Refract Surg 1996; 12:304–306
I believe the surgical technique described is safe and 9. Jensen OM, Haamann P, Schmidt P. Penetrating keratoplasty
reproducible and should be considered as an option and transscleral fixation of posterior chamber lens. Acta Oph-
in aphakic eyes that lack capsule support and require thalmol Scand 1995; 73:551–554
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J CATARACT REFRACT SURG - VOL 36, MARCH 2010