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Phacoemulsification after Penetrating Keratoplasty with Autologous Limbal Transplant and Amniotic Membrane Transplant in Chemical Burns

Arora, Ritu MD, DNB; Narayanan, R MS; Jain, Shailley MS; Raina, Usha K MD, FRCS, FRC ophth; Mehta, D K MS, MNAMS

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Indian Journal of Ophthalmology: Apr–Jun 2005 - Volume 53 - Issue 2 - p 121-123
doi: 10.4103/0301-4738.16176
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Cataract surgery in post-keratoplasty patients needs extra precautions, as the risk of graft failure is high. Phacoemulsification with keratoplasty as a single stage procedure has been reported earlier,1234 but there are no reports of cataract surgery in cases of alkali burns with operated penetrating keratoplasty (PKP) with autologous limbal transplant (ALT) and amniotic membrane transplant (AMT). We herein describe a patient who underwent phacoaspiration in the third sitting (post AMT, ALT and PKP).

Case Report

A 26-year-old male patient presented to the cornea service in May 2000 with injury to the left eye with lime particles 10 months earlier. At presentation, the patient had a vision of hand movement close to face with accurate projection of rays in the left eye. Ocular examination showed a total symblepharon in the superonasal quadrant with an extensively vascularised and opaque cornea [Figure 1]. Rest of the anterior segment structures could not be visualised through the corneal opacity. The right eye was normal with a visual acuity of 6/6. Symblepharon release with superficial keratectomy and amniotic membrane transplant (AMT) was performed as a first stage procedure. The cornea cleared partially with a significant decrease in the degree of corneal vascularisation over the next 6 months and the patient′s vision improved to counting fingers at 2 feet [Figure 2]. In February 2001, the patient underwent a second stage autologous limbal transplant (ALT) with penetrating keratoplasty (PKP) in a single sitting. Two limbal lenticules of 2′ o clock hours each were harvested from the fellow eye and sutured at 6′ to 8′ clock hours and 9′ to 11′ clock hours respectively. Following ALT, a graft of 6.5 mm size was placed on centrally 6.0 mm trephined host cornea. Per-operatively the crystalline lens was clear. Post-keratoplasty, the patient achieved a best-corrected visual acuity of 6/18 with a clear graft at 8 weeks. However, 3 months later, the visual acuity deteriorated due to a posterior subcapsular cataract, which gradually increased to a total cataract [Figure 3]. A cataract surgery was scheduled for February 2002. The IOL power was calculated using the central corneal power as calculated by topography. A specular microscopy of the graft before cataract surgery showed an endothelial cell count of 2000 cells/mm2 with minimal pleomorphism and polymegathism. Preoperatively, the patient was started on topical prednisolone acetate 1% (6 times a day) and systemic prednisolone (2 mg/kg). Phacoaspiration was performed through a superotemporal posterior limbal incision with corneal valve. As it was difficult to raise a conjunctival flap due to extensive scarring in the subconjunctival tissues, a linear 3.2 mm posterior limbal incision was made at the 2′o clock position avoiding the nasal limbal lenticules. Extreme caution had to be exercised for construction of the wound, because of difficult visualisation of the intracorneal dissection of the tunnel. A clear corneal wound was not considered because of the risk of damage to the graft endothelium. Anterior capsulorrhexis was done after staining the capsule with trypan blue. A soft-shell technique1 with Viscoat® (chondroitin sulfate 4.0% - sodium hyaluronate 3.0%, Alcon Laboratories) and Healon® GV (sodium hyaluronate 1.4%, Pharmacia and Upjohn) was employed. The aspiration flow rate was kept at 18 cc/min while the maximum vacuum limits was set at 100 mm Hg. The bottle height was kept at 70 cm, and it was ensured that the anterior chamber did not collapse throughout the surgery. A 6.0 mm optic diameter acrylic foldable intraocular lens (MA60BA Acrysof, Alcon) was inserted in the bag and the wound was left sutureless. The graft has been clear from the first postoperative day with minimal anterior chamber reaction [Figure 4], with a best-corrected visual acuity of 6/18 in the left eye at 8 weeks′ follow-up, which was maintained at the last follow-up visit 10 months post-operatively. Post-surgery, the specular microscopy of the graft showed an endothelial cell count of 1800 cells/mm2 with minimal pleomorphism and polymegathism.

Figure 1:
Clinical photograph of the patient at presentation. The cornea is opaque and extensively vascularised and a symblepharon can be appreciated superonasally
Figure 2:
Post AMT the cornea has cleared partially and vascularisation has regressed
Figure 3:
A clear corneal graft with cataract one year after penetrating keratoplasty and ALT
Figure 4:
Ten months post cataract surgery, the graft is clear with a visual acuity of 6/18


Various authors have reported performing a combined procedure of phacoemulsification and keratoplasty with in-the-bag implantation of IOL. Both open-sky and closed system phacoemulsification techniques have been successfully used in the management of patients with concurrent corneal disease and cataract.2345 However, phacoemulsification post-PK in a patient with prior chemical injury with extensive corneal and subconjunctival scarring necessitates additional precautions. The graft in these cases is at risk because of co-existent dry eye and limbal ischaemia.

Extensive subconjunctival scarring makes it difficult to raise a conjunctival flap and the anatomy of the limbus is not well defined. The site of incision has to be selected with a view to minimise any possible damage to the limbal grafts. In this case, as the limbal lenticules were placed from 6-11 o′ clock, the tunnel was made at 2′o clock. A posterior limbal incision was preferred to a scleral tunnel as there was extensive fibrosis in the conjunctiva; raising a conjunctival flap and scleral tunnel dissection was not feasible. Moreover, the corneal entry could be made a little posterior with this incision as compared to a clear corneal incision, which decreases the chances of endothelial damage in the graft.

Previous studies using the two-stage procedure, describe extracapsular cataract extraction with the occurrence of graft failure ranging from 0 to 66%.67 The use of the soft-shell technique helps in protecting the endothelium during surgery. Low aspiration flow rate and vacuum also reduce the turbulence within the anterior chamber during phacoemulsification and decrease endothelial cell loss. Our case shows that phacoaspiration using the soft-shell technique in cases of operated PKP, ALT and AMT for chemical burns can be a safe procedure. Extra caution has to be taken during wound construction to ensure that no damage occurs to limbal grafted areas, which are essential for graft survival in these patients.

1. Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique J Cataract Refract Surg. 1999;25:167–73
2. Rao SK, Padmanabhan P. Combined pahcoemulsification and penetrating keratoplasty Ophthalmic Surg Lasers. 1999;30:488–91
3. Malbran ES, Malbran E, Buonasanti J, Androgen E. Closed-system phacoemulsification and posterior chamber implant combined with penetrating keratoplasty Ophthalmic Surg. 1993;24:403–6
4. Robin H, Hannouche D, Hoang-Xuan T. Triple procedure with phacoemulsification prior to grafting J Fr Ophthalmol. 1997;20:701–3
5. Lindquist TD. Open-sky phacoemulsification during corneal transplantation Ophthalmic Surg. 1994;25:734–6
6. Geggel HS. Intraocular lens implantation after penetrating keratoplasty Ophthalmology. 1994;101:113–9
7. Hughes WF. The treatment of cornea dystrophies by keratoplasty Am J Ophthalmol. 1960;50:1100–14

Proprietary Interest: None


Post-keratoplasty phacoemulsification; chemical burns; autologous limbal cell transplant; amniotic membrane transplant

© 2005 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow