Simultaneous Penetrating Keratoplasty, Cataract Removal and Intraocular Lens Implantation in Tuzla, Bosnia and Herzegovina.

INTRODUCTION: It is known that simultaneous penetrating keratoplasty, cataract removal and intraocular lens implantation are always a big challenge to a surgeon, especially in developing countries such as Bosnia and Herzegovina. In these cases there is always a higher rate of different kind of intraoperative complications. Phacoemulsification after penetrating keratoplasty especially in older people may cause significant endothelial injury and also could affect long term graft survival. AIM: The aim of this report is to describe one of these challenging cases and the possible ways to manage them in developing countries. CASE REPORT: In this paper we report a case of a 46 year-old female patient, with a cataract on her right eye with a central corneal leukoma. She reported that when she was 6 years old, she had an eye injury with corn leaf. At the age of 10 year she reported that she had another injury of the same eye with a glass. She reported that she wasn't seeing quite good after that. Three years ago she had a transplantation of amniotic membrane due ulcer on the same eye. She reported also that even after this procedure she wasn't seeing quite good. Now she was admitted to hospital for a triple surgical procedure. At that moment patient has been ophthalmological examined (visual acuity testing, biomicroscopy, tonometry, ultrasound of both eyes with biometry and ophthalmoscopy). At the day of admission to the hospital on slit lamp we found central corneal leukoma, occlusion of pupil and complicated cataract. Before surgery her Uncorrected distance visual acuity (UDVA) on her left eye was light perception. A combined procedure of penetrating keratoplasty (PKP), open-sky cataract extraction, and intraocular lens (IOL) implantation was planned. Thirty days after surgery her visual acuity was 0,5 without correction. It is concluded that cataract surgery in patients after keratoplasty is more complicated.
CONCLUSION: Therefore, these patients should be managed with utmost care and operated by an experienced surgeon.

INTRODUCTION

Corneal pathologies which can include different shape scars and opacities may very often coincide with different grades of cataracts. This is very commune in older population. It is well known that corneal eye diseases are the fourth most common cause of blindness (after cataracts, glaucoma and age-related macular degenerations) and affects more than 10 million people worldwide (1).

Good condition of cornea is crucial to achieve good outcome after cataract extraction with intraocular lens implantation. It is very important to have a good corneal clarity. Many times during our praxis we have seen that the corneal opacity and cataract present together. In such cases, performing only penetrating keratoplasty or only cataract surgery does not give good visual outcome and in the end we have unsatisfied patient and as well unsatisfied surgeon. Actually corneal pathologies needing keratoplasty are often associated with cataract and therefore combined surgery is very often not only necessary, it is more often mandatory. Triple procedure with penetrating keratoplasty and simultaneous cataract extraction with intra ocular lens (IOL) implantation is usually preferred as single step surgery because theoretically visual rehabilitation is more rapid and patients require less postoperative follow ups (2–5).

Combined surgery including penetrating keratoplasty (PK), cataract extraction, and intraocular lens (IOL) implantation (often termed the triple procedure) is a well-established and effective surgical treatment in such cases worldwide. In Eye Clinic of University Clinic Center Tuzla, Bosnia and Herzegovina with limited ophthalmic instruments and equipment it is possible to manage this very complicated cases. Since several years it is possible to perform open-sky vitrectomy which allows to surgeon better access for surgical instruments, especially to anterior fundus structures. The technique also improves the visibility of intraocular structures.

CASE REPORT

We report a case of a 46 year-old female patient, with a cataract on her right eye with a central corneal leukoma. Patient reported during one of the examination prior to the surgery that when she was 6 years old, patient had an eye injury with corn leaf. At the age of 10 year patient reported that she had another injury of the same eye with a glass. Patient also said that she wasn’t seeing quite well after that. Patient reported that she wasn’t under any medical therapy or that she was wearing contact lenses or glasses. Three years ago patient had a transplantation of amniotic membrane due ulcer on the same eye in different hospital then ours. Now she was admitted to hospital for a triple surgical procedure.

Ocular examination on admission day to hospital revealed patients best uncorrected distance visual acuity (UDVA) to be light perception on patient RE (right eye) and 1.0 with out any correction LE (left eye). Results on patient slit lamp revealed on the right eye corneal edema with a central leukoma, with a complicated cataract and partial seclusion of pupil and no pathological findings on left eye. Patients pupil size were equals. Patient ocular movements were normal in all gazes. Intraocular pressure (IOP) was also normal. Examination of the left eye was normal. The vitreous was quiet and retinal vessels were of normal caliber. Details on the founds of right eye were impossible to asses due the changes in anterior segment. We performed ultrasound examination and we performed intraocular lens calculation. Due pathological changes on the right eye we were unable to accurately measure the true corneal power values so we performed intraocular lens calculation for the left eye. Before the surgical procedure patient was treated with Prednisone 80 mg intravenous and as well systematic antibiotics with local corticosteroids and antibiotics (Figure 1). The pupil was dilated preoperatively with tropicamide 1% eye drops. Before surgical procedure a good quality donor cornea was retrieved from a cadaveric transplantation.

Figure 1.

Preoperative anterior segment of the eye

After informed consent was obtained, operation was performed in general anesthesia. After excision of the opaque recipient cornea, a cataract was seen. Before the staining of anterior capsule, surgeon performed excision of pupillary membrane and synechiolysis. The anterior capsule was initially stained with VisionBlue (Dutch Ophthalmic, USA). Cataract extraction with IOL implantation (open sky) was performed under operating microscopes Operative Microscope OPMI Visu 150 Carl Zeiss Meditec Inc, Dublin, using Alcon Infiniti® Vision System Fort Worth Texas USA, sodium hyaluronate (Provisc® Alcon) as viscoelastic and surgical instruments Alcon and Geuder AG Heidelberg Germany. After placing four cardinal sutures, the donor button was fixed to the recipient using separate 10/0 nylon sutures. (Figure 2). Follow-up examinations were performed on days 1, 3, 7, and 30 days. Thirty days after surgery her UDVA was 0,5. The patients received topical antibiotic and corticosteroids. Postoperatively, if keratometric astigmatism exceeded 4.0 D, tension of the running sutures was adjusted after 1 to 2 months, and selective removal of separate sutures began after 2 months. Currently patients visual acuity is 0.6 without correction.

Figure 2.

Anterior segment at the end of triple procedure:

CONCLUSION

It is very important to remember that triple procedure in ophthalmology can have different meanings. Most ophthalmologist refer triple procedure to be combined penetrating keratoplasty, cataract extraction, and intraocular lens implantation. But sometimes it refers to other ophthalmic surgical combinations. In our case we refer to triple procedure the combined simultaneous penetrating keratoplasty (PK), cataract removal and intraocular lens implantation The greatest advantage of the this triple procedure is that it can obviate the expense and inconvenience of a second procedure, which is of great benefit for the older patients. Also one main advantage of the triple procedure is the faster visual rehabilitation. After triple procedure, one of disadvantage some postoperative refractive error may be a problem and provide visual limitations after PKP. In very high percentage of cases we have seen high-degree astigmatism and anisometropia (6, 7). In young accommodative patients, these residual refractive errors may be corrected using spectacles, contact lens or even different surgical options (8-15). Also it is very important and essential to accurately predict IOL power, to perform reliable keratometry readings, anterior chamber depth and axial length measurements. In contrast to cataract surgery alone, all of these parameters may alter following the triple procedure, increasing the risk of unanticipated refractive errors (16). In our opinion triple procedure including cataract extraction via open sky in general anesthesia is the method of choice for combined lens and corneal opacities (17).